| Doctor Name: | PHILIP LICIS |
| NPI Number: | 1033154224 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | LCDP |
| License Number: | LCDP00037 |
| Business Practice Address: | 111 Howard Ave Bldg 56 Cranston, RI - 029203001 |
| Business Phone Number: | 4014621020 |
| Business Fax Number: | |
| Mailing Address: | 528 N Main St, PROVIDENCE |
| State: | RI |
| Postal Code: | 029045757 |
| Phone Number: | |
| Fax Number: | |
| NPI Enumeration Date: | 06/19/2006 |
| NPI Last Update Date: | 03/30/2009 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YA0400X |
| License Number: | LCDP00037 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | RI |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Addiction (Substance Use Disorder) |
| Taxonomy Definition: | |