Healthcare Provider Details

I. General information

NPI: 1871198556
Provider Name (Legal Business Name): LICASA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2020
Last Update Date: 12/01/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7041 RESEDA BLVD
RESEDA CA
91335-4209
US

IV. Provider business mailing address

7041 RESEDA BLVD
RESEDA CA
91335-4209
US

V. Phone/Fax

Practice location:
  • Phone: 818-210-6612
  • Fax:
Mailing address:
  • Phone: 818-210-6612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: LILIT MURADYAN
Title or Position: CEO
Credential:
Phone: 818-210-6612