Provider Demographics
NPI:1215439336
Name:GALLAGHER-LICITRA, CASEY M (RN, PMHNP)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:M
Last Name:GALLAGHER-LICITRA
Suffix:
Gender:F
Credentials:RN, PMHNP
Other - Prefix:
Other - First Name:CASEY
Other - Middle Name:
Other - Last Name:GALLAGHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:102 ARMSTRONG RD
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:NY
Mailing Address - Zip Code:14882-8904
Mailing Address - Country:US
Mailing Address - Phone:607-427-9970
Mailing Address - Fax:
Practice Address - Street 1:201 E GREEN ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-5635
Practice Address - Country:US
Practice Address - Phone:607-274-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-05
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY736778163W00000X
NYF405994363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered Nurse