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General NPI Number Information
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NPI Number | 1376272468
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Entity Type | Individual
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Provider Name | ALEXANDRIA D LICEA LCSW
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Gender | Female
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Dates
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Enumeration Date | 06/06/2022
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Last Update Date | 06/06/2022
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Provider Practice Location Address
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Address Line | 1325 N 63RD ST
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City | WACO
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State | TX
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Zip | 76710-4111
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Country | US
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Telephone | 254-300-7591
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Fax |
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Provider Business Mailing Address
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Address Line | 2115 STEPHENS PL STE 400A
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City | NEW BRAUNFELS
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State | TX
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Zip | 78130-2167
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Country | US
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Telephone | 830-282-7980
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Fax |
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 60219
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License Number State | TX
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