Healthcare Provider Details

I. General information

NPI: 1437654217
Provider Name (Legal Business Name): MICHAEL PAUL LICHT II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2018
Last Update Date: 03/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4309 3RD AVE
SAN DIEGO CA
92103-1407
US

IV. Provider business mailing address

3825 47TH ST APT 6
SAN DIEGO CA
92105-2863
US

V. Phone/Fax

Practice location:
  • Phone: 619-876-4502
  • Fax:
Mailing address:
  • Phone: 858-952-8295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number95114434
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number95114434
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: