Provider Demographics
NPI:1649500786
Name:LICKMAN, VICTORIA FAY (MT)
Entity type:Individual
Prefix:MS
First Name:VICTORIA
Middle Name:FAY
Last Name:LICKMAN
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 W BROAD STREET, #1
Mailing Address - Street 2:
Mailing Address - City:CHESANING
Mailing Address - State:MI
Mailing Address - Zip Code:48616-1001
Mailing Address - Country:US
Mailing Address - Phone:989-845-7464
Mailing Address - Fax:
Practice Address - Street 1:805 W BROAD ST # 1
Practice Address - Street 2:
Practice Address - City:CHESANING
Practice Address - State:MI
Practice Address - Zip Code:48616-1001
Practice Address - Country:US
Practice Address - Phone:989-845-7464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-13
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist