Provider Demographics
NPI:1871198556
Name:LICASA INC
Entity Type:Organization
Organization Name:LICASA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LILIT
Authorized Official - Middle Name:
Authorized Official - Last Name:MURADYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-210-6612
Mailing Address - Street 1:7041 RESEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-4209
Mailing Address - Country:US
Mailing Address - Phone:818-210-6612
Mailing Address - Fax:
Practice Address - Street 1:7041 RESEDA BLVD
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-4209
Practice Address - Country:US
Practice Address - Phone:818-210-6612
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility