Provider Demographics
NPI:1952773772
Name:SPINA, LICIA (MS, 6TH YEAR)
Entity Type:Individual
Prefix:
First Name:LICIA
Middle Name:
Last Name:SPINA
Suffix:
Gender:F
Credentials:MS, 6TH YEAR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3219 O ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20007-2843
Mailing Address - Country:US
Mailing Address - Phone:860-307-5722
Mailing Address - Fax:
Practice Address - Street 1:3219 O ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20007-2843
Practice Address - Country:US
Practice Address - Phone:860-307-5722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-21
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTC072015001831103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool