Provider Demographics
NPI:1831963685
Name:LICON, JOSEPH
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:LICON
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:PO BOX 9402
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92375-2602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13261 SPRING VALLEY PARKWAY
Practice Address - Street 2:STE 205
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395
Practice Address - Country:US
Practice Address - Phone:442-243-2714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA137300106H00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health