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General NPI Number Information
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NPI Number | 1215421979
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Entity Type | Individual
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Provider Name | LISA LICEAGA DO
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Gender | Female
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Dates
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Enumeration Date | 06/17/2018
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Last Update Date | 09/04/2025
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Provider Practice Location Address
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Address Line | 11100 EUCLID AVE
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City | CLEVELAND
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State | OH
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Zip | 44106-1716
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Country | US
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Telephone | 216-844-8447
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 947407
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City | ATLANTA
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State | GA
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Zip | 30394-7407
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Country | US
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Telephone | 941-917-2600
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Fax | 941-917-7884
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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 | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | 34.015963
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | OS19884
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License Number State | FL
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