Healthcare Provider Details

I. General information

NPI: 1184400285
Provider Name (Legal Business Name): KAYLAN LICAUSI ASW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2023
Last Update Date: 09/05/2023
Certification Date: 09/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3075 ADELINE ST STE 280
BERKELEY CA
94703-2580
US

IV. Provider business mailing address

490 LAKE PARK AVE. #16172
OAKLAND CA
94610
US

V. Phone/Fax

Practice location:
  • Phone: 510-981-4100
  • Fax:
Mailing address:
  • Phone: 510-914-8884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number117156
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: