Provider Demographics
NPI:1205546199
Name:LICCESE, CHARLES
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:LICCESE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1816 ALBERMARLE AVE
Mailing Address - Street 2:
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554-1617
Mailing Address - Country:US
Mailing Address - Phone:516-315-1641
Mailing Address - Fax:
Practice Address - Street 1:1816 ALBERMARLE AVE
Practice Address - Street 2:
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554-1617
Practice Address - Country:US
Practice Address - Phone:516-315-1641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-01
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NYF405204-01363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program