Provider Demographics
NPI:1215729082
Name:LICONA, ENRIQUE (MSW, SUDPT)
Entity type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:
Last Name:LICONA
Suffix:
Gender:M
Credentials:MSW, SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 ORCHARDVALE RD
Mailing Address - Street 2:
Mailing Address - City:ZILLAH
Mailing Address - State:WA
Mailing Address - Zip Code:98953-9021
Mailing Address - Country:US
Mailing Address - Phone:509-790-8016
Mailing Address - Fax:509-790-8016
Practice Address - Street 1:120 S 3RD ST
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98901-2875
Practice Address - Country:US
Practice Address - Phone:509-865-6705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-19
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61681564101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)