Healthcare Provider Details

I. General information

NPI: 1215421979
Provider Name (Legal Business Name): LISA LICEAGA DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2018
Last Update Date: 09/04/2025
Certification Date: 09/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11100 EUCLID AVE
CLEVELAND OH
44106-1716
US

IV. Provider business mailing address

PO BOX 947407
ATLANTA GA
30394-7407
US

V. Phone/Fax

Practice location:
  • Phone: 216-844-8447
  • Fax:
Mailing address:
  • Phone: 941-917-2600
  • Fax: 941-917-7884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number34.015963
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberOS19884
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: