Provider Demographics
NPI:1063127793
Name:LISICKI, AMY
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:LISICKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 CENTINELA AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90302-1579
Mailing Address - Country:US
Mailing Address - Phone:310-988-6179
Mailing Address - Fax:
Practice Address - Street 1:520 N LA BREA AVE
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90302-3049
Practice Address - Country:US
Practice Address - Phone:323-294-4932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-17
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14560101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)