Basic Information
| Provider Information | |||||||||
| NPI: | 1689163172 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LICINI | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | ROSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5200 COPPER AVE NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871081473 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5200 COPPER AVE NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871081473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052665557 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2018 | ||||||||
| LastUpdateDate: | 05/09/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.