Basic Information
| Provider Information | |||||||||
| NPI: | 1417573676 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LICON | ||||||||
| FirstName: | CHLOE | ||||||||
| MiddleName: | IVANA | ||||||||
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| Credential: | AMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11251 | ||||||||
| Address2: | |||||||||
| City: | PALM DESERT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922551251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4424004746 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 555 N PERRIS BLVD BLDG A | ||||||||
| Address2: | |||||||||
| City: | PERRIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925712811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9514365300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2020 | ||||||||
| LastUpdateDate: | 03/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.