Provider Demographics
NPI:1093557050
Name:LICKWOLA, ANNETTE (LADC)
Entity type:Individual
Prefix:MRS
First Name:ANNETTE
Middle Name:
Last Name:LICKWOLA
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:931 BANK ST
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-2702
Mailing Address - Country:US
Mailing Address - Phone:860-574-8256
Mailing Address - Fax:
Practice Address - Street 1:931 BANK ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-2702
Practice Address - Country:US
Practice Address - Phone:860-574-8256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-11
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT44.001570101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)