Provider Demographics
NPI:1972643880
Name:LICATA, DAMIEN J (BA)
Entity Type:Individual
Prefix:MR
First Name:DAMIEN
Middle Name:J
Last Name:LICATA
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 ELM ST
Mailing Address - Street 2:
Mailing Address - City:KEENE
Mailing Address - State:NH
Mailing Address - Zip Code:03431-3052
Mailing Address - Country:US
Mailing Address - Phone:603-357-5270
Mailing Address - Fax:603-357-6875
Practice Address - Street 1:17 93RD ST
Practice Address - Street 2:
Practice Address - City:KEENE
Practice Address - State:NH
Practice Address - Zip Code:03431-3748
Practice Address - Country:US
Practice Address - Phone:603-357-5270
Practice Address - Fax:603-357-6875
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH171M00000XMedicare UPIN