Provider Demographics
NPI:1154805471
Name:LICKISS, WILLIAM THOMAS
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:THOMAS
Last Name:LICKISS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13947 S NEWBURG DR
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-6787
Mailing Address - Country:US
Mailing Address - Phone:801-506-6695
Mailing Address - Fax:
Practice Address - Street 1:13947 S NEWBURG DR
Practice Address - Street 2:
Practice Address - City:HERRIMAN
Practice Address - State:UT
Practice Address - Zip Code:84096-6787
Practice Address - Country:US
Practice Address - Phone:801-506-6695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-21
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14060937-2506103K00000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No172V00000XOther Service ProvidersCommunity Health Worker