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NPI Code Detail

MEDICARE: MRS. KERRI S. LICINI MA, MAED., BCBA

MEDICARE: MRS. KERRI S. LICINI MA, MAED., BCBA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103K00000XBehavior Analyst

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11-13-14323OTHER1-13-14323

General Provider Information

NPI Number : 1003119504
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. KERRI S. LICINI MA, MAED., BCBA
Provider Business Mailing Address
First Line : 782 FOXRIDGE CENTER DR
Second Line :
City : ORANGE PARK
State : FL
Zip : 32065-5776
Country : US
Telephone Number : 904-637-1400
Fax Number : 904-637-1400
Provider Business Practice Location Address
First Line : 782 FOXRIDGE CENTER DR
Second Line :
City : ORANGE PARK
State : FL
Zip : 32065-5776
Country : US
Telephone Number : 904-637-1400
Fax Number : 904-800-4880
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/06/2010
Last Update Date : 07/28/2024

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