Provider Demographics
NPI:1912436957
Name:LICONA, CHRISTINA (LMT)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:LICONA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7905 N 122ND EAST AVE
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-3529
Mailing Address - Country:US
Mailing Address - Phone:918-277-1242
Mailing Address - Fax:
Practice Address - Street 1:12806 E 86TH PL N
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-2687
Practice Address - Country:US
Practice Address - Phone:918-277-1242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-04
Last Update Date:2017-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK156805225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist