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General NPI Number Information
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NPI Number | 1003117268
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Entity Type | Individual
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Provider Name | SUSAN J LICOAN PSYD
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Gender | Female
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Dates
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Enumeration Date | 11/04/2010
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Last Update Date | 05/12/2013
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Provider Practice Location Address
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Address Line | 39 3301 MILO PLACE
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City | OOKALA
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State | HI
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Zip | 96774
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Country | US
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Telephone | 808-896-7186
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Fax | 808-962-6943
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Provider Business Mailing Address
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Address Line | PO BOX 1578
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City | HONOKAA
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State | HI
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Zip | 96727-1578
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Country | US
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Telephone | 808-896-7186
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Fax | 808-962-6943
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 1214
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License Number State | HI
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