MEDICARE: HEIDI LANO LICUDAN

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	106E00000X	Assistant Behavior Analyst	0134000621	VA

General Provider Information

NPI Number	:	1457912537
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEIDI LANO LICUDAN

Provider Business Mailing Address
First Line	:	667 ANNAKA LOOP
Second Line	:
City	:	CHESAPEAKE
State	:	VA
Zip	:	23323-2111
Country	:	US
Telephone Number	:	757-403-6697
Fax Number	:

Provider Business Practice Location Address
First Line	:	4001 VIRGINIA BEACH BLVD STE 117
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23452-1759
Country	:	US
Telephone Number	:	855-832-6727
Fax Number	:	772-675-9100

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

Provider Enumeration Date	:	06/27/2019
Last Update Date	:	09/18/2025

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