Provider Demographics
NPI:1992861843
Name:LICETI, ROSE (LPC, LIBSW)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:LICETI
Suffix:
Gender:F
Credentials:LPC, LIBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7451 NDCBU
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6258
Mailing Address - Country:US
Mailing Address - Phone:505-737-0375
Mailing Address - Fax:
Practice Address - Street 1:7451 NDCBU
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571
Practice Address - Country:US
Practice Address - Phone:505-737-0375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4342101YM0800X
NMB-2183104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM100312OtherVALUE OPTIONS