Healthcare Provider Details

I. General information

NPI: 1770133456
Provider Name (Legal Business Name): KARA MARIE LICTAWA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2019
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38219 MOUND RD STE 102
STERLING HEIGHTS MI
48310-3466
US

IV. Provider business mailing address

1721 MOON LAKE BLVD STE 140
HOFFMAN ESTATES IL
60169-1070
US

V. Phone/Fax

Practice location:
  • Phone: 312-965-2997
  • Fax: 312-929-0324
Mailing address:
  • Phone: 312-965-2997
  • Fax: 312-929-0324

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: