MEDICARE: KATHERINE LINCICUM LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker		CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093097826
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHERINE LINCICUM LICSW

Provider Business Mailing Address
First Line	:	11303 W WASHINGTON BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90066-6003
Country	:	US
Telephone Number	:	310-482-3260
Fax Number	:

Provider Business Practice Location Address
First Line	:	6957 CALIFORNIA AVE SW
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98136-1953
Country	:	US
Telephone Number	:	206-938-5947
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/19/2011
Last Update Date	:	10/27/2022

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