Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103G00000X | Clinical Psychologist | 1214 | HI |
Y | 103TC0700X | Clinical Psychologist | 1214 | HI |
NPI | 1003117268 |
---|---|
Provider Name | Susan J Licoan |
First Address | Honokaa, HI 96727-1578 |
Second Address | Ookala, HI 96774 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/11/2010 |
Last Update Date | 12/05/2013 |