MEDICARE: KAYLEE RAE LICCIARDI LAC

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	101YM0800X	Mental Health Counselor	LAC-22465	AZ

General Provider Information

NPI Number	:	1255196333
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAYLEE RAE LICCIARDI LAC

Provider Business Mailing Address
First Line	:	2120 S MCCLINTOCK DR STE 105
Second Line	:
City	:	TEMPE
State	:	AZ
Zip	:	85282-2692
Country	:	US
Telephone Number	:	480-804-0326
Fax Number	:

Provider Business Practice Location Address
First Line	:	2120 S MCCLINTOCK DR STE 105
Second Line	:
City	:	TEMPE
State	:	AZ
Zip	:	85282-2692
Country	:	US
Telephone Number	:	480-804-0326
Fax Number	:

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

Provider Enumeration Date	:	02/16/2024
Last Update Date	:	04/13/2026

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1497036248 — LINDSAY LUMAN-LATSHAW LCSW
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1013974914 — CHRISTIA J. LEWIS LPC
Practice Location Address:

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1245285329 — SUSAN MARIE MCCORD LCSW
Practice Location Address:

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1649283532 — MRS. ALICIA JANETTE KOSTOV LCSW
Practice Location Address:

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