Healthcare Provider Details

I. General information

NPI: 1275986507
Provider Name (Legal Business Name): MARIE D ROY LICIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2016
Last Update Date: 07/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9406 JAMAICA AVE
WOODHAVEN NY
11421-2221
US

IV. Provider business mailing address

15 EDDIE AVE
NORTH BABYLON NY
11703-2712
US

V. Phone/Fax

Practice location:
  • Phone: 631-366-3876
  • Fax:
Mailing address:
  • Phone: 631-949-8392
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number020736
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: