Provider Demographics
NPI:1205115748
Name:FAZLICIC, LEJLA (LIC AC)
Entity type:Individual
Prefix:
First Name:LEJLA
Middle Name:
Last Name:FAZLICIC
Suffix:
Gender:F
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4751 W TOUHY AVE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:LINCOLNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60712-1654
Mailing Address - Country:US
Mailing Address - Phone:847-983-0136
Mailing Address - Fax:224-534-7139
Practice Address - Street 1:4751 W TOUHY AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:LINCOLNWOOD
Practice Address - State:IL
Practice Address - Zip Code:60712-1654
Practice Address - Country:US
Practice Address - Phone:847-983-0136
Practice Address - Fax:224-534-7139
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-16
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198000990171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist