Provider Demographics
NPI:1952678336
Name:LICHT, GENEVA MARY
Entity Type:Individual
Prefix:
First Name:GENEVA
Middle Name:MARY
Last Name:LICHT
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:P.O.B. 15408
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93406
Mailing Address - Country:US
Mailing Address - Phone:415-497-8212
Mailing Address - Fax:
Practice Address - Street 1:227 SOUTH ST. STE Y
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401
Practice Address - Country:US
Practice Address - Phone:415-497-8212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-29
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health