Provider Demographics
NPI:1134837685
Name:LICITRA, LEANNE
Entity type:Individual
Prefix:
First Name:LEANNE
Middle Name:
Last Name:LICITRA
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 1:26 MANDEVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEQUANNOCK
Mailing Address - State:NJ
Mailing Address - Zip Code:07440-1538
Mailing Address - Country:US
Mailing Address - Phone:973-897-9397
Mailing Address - Fax:
Practice Address - Street 1:100 HOBOKEN AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07310-1028
Practice Address - Country:US
Practice Address - Phone:973-897-9397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist