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NPI Code Detail

MEDICARE: SERENA MARIE LICASTRO L.MT

MEDICARE: SERENA MARIE LICASTRO L.MT
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
1225700000XMassage Therapist030763NY

General Provider Information

NPI Number : 1255151510
Entity Type Code : Individual
Provider Name (Legal Business Name) : SERENA MARIE LICASTRO L.MT
Provider Business Mailing Address
First Line : 130 ROSE AVE
Second Line :
City : STATEN ISLAND
State : NY
Zip : 10306-2241
Country : US
Telephone Number : 718-909-3819
Fax Number :
Provider Business Practice Location Address
First Line : 130 ROSE AVE
Second Line :
City : STATEN ISLAND
State : NY
Zip : 10306-2241
Country : US
Telephone Number : 718-909-3819
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/11/2024
Last Update Date : 01/29/2026

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