Healthcare Provider Details

I. General information

NPI: 1285204354
Provider Name (Legal Business Name): VICTORIA LICANDRO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2021
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 COURT ST STE 1303
BROOKLYN NY
11242-1113
US

IV. Provider business mailing address

26 COURT ST STE 1303
BROOKLYN NY
11242-1113
US

V. Phone/Fax

Practice location:
  • Phone: 845-709-7390
  • Fax:
Mailing address:
  • Phone: 347-338-8965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number103339
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2614200
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberTPIC54
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: