Provider Demographics
NPI:1922319979
Name:LUNA, LICIA LEE
Entity Type:Individual
Prefix:
First Name:LICIA
Middle Name:LEE
Last Name:LUNA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 623
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95009-0623
Mailing Address - Country:US
Mailing Address - Phone:831-359-6627
Mailing Address - Fax:
Practice Address - Street 1:8352 CHURCH ST
Practice Address - Street 2:SUITE C
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-4449
Practice Address - Country:US
Practice Address - Phone:408-848-6511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-24
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CAMFC 52440106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health