Provider Demographics
NPI:1912442351
Name:LICEAGA, ESTHER MARIE
Entity Type:Individual
Prefix:
First Name:ESTHER
Middle Name:MARIE
Last Name:LICEAGA
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:ESTHER
Other - Middle Name:MARIE
Other - Last Name:LICEAGA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8205 SW 11TH CT
Mailing Address - Street 2:
Mailing Address - City:NORTH LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33068-3418
Mailing Address - Country:US
Mailing Address - Phone:787-231-6166
Mailing Address - Fax:
Practice Address - Street 1:8205 SW 11TH CT
Practice Address - Street 2:
Practice Address - City:NORTH LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33068-3418
Practice Address - Country:US
Practice Address - Phone:787-231-6166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-20
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health