Provider Demographics
NPI:1316789803
Name:LICITRA, JOSHUA JORDAN
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:JORDAN
Last Name:LICITRA
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 1:25845 NIMES CT
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692-5273
Mailing Address - Country:US
Mailing Address - Phone:949-873-3002
Mailing Address - Fax:
Practice Address - Street 1:25845 NIMES CT
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92692-5273
Practice Address - Country:US
Practice Address - Phone:949-873-3002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-06
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling