Basic Information
| Provider Information | |||||||||
| NPI: | 1437654217 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LICHT | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | PAUL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | II | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3825 47TH ST APT 6 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921052863 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8589528295 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4309 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921031407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6198764502 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2018 | ||||||||
| LastUpdateDate: | 03/26/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0807X | 95114434 | CA | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Child & Adolescent | 163WP0808X | 95114434 | CA | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.