Provider Demographics
NPI:1467487017
Name:LOCICERO, ALICE K (PH D)
Entity type:Individual
Prefix:DR
First Name:ALICE
Middle Name:K
Last Name:LOCICERO
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6219 JORDAN AVE
Mailing Address - Street 2:
Mailing Address - City:EL CERRITO
Mailing Address - State:CA
Mailing Address - Zip Code:94530-1551
Mailing Address - Country:US
Mailing Address - Phone:617-686-6606
Mailing Address - Fax:
Practice Address - Street 1:6219 JORDAN AVE
Practice Address - Street 2:
Practice Address - City:EL CERRITO
Practice Address - State:CA
Practice Address - Zip Code:94530-1551
Practice Address - Country:US
Practice Address - Phone:617-686-6606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1711103TC0700X, 103TC2200X, 103T00000X
CA29068103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW0180401Medicare UPIN
MAW01804Medicare UPIN
MAW01804Medicare ID - Type Unspecified