MEDICARE: MISS SARA LICON LCSW

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	80557	CA

General Provider Information

NPI Number	:	1760681316
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS SARA LICON LCSW

Provider Business Mailing Address
First Line	:	801 E KATELLA AVE
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92805-6614
Country	:	US
Telephone Number	:	714-922-4117
Fax Number	:

Provider Business Practice Location Address
First Line	:	303 W LINCOLN AVE STE 105
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92805-2928
Country	:	US
Telephone Number	:	714-922-4117
Fax Number	:

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

Provider Enumeration Date	:	07/13/2007
Last Update Date	:	05/30/2023

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