Provider Demographics
NPI:1407363047
Name:LYCKE, KATHERINE LOUISE (MED)
Entity type:Individual
Prefix:MS
First Name:KATHERINE
Middle Name:LOUISE
Last Name:LYCKE
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4595 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-2058
Mailing Address - Country:US
Mailing Address - Phone:904-448-4700
Mailing Address - Fax:
Practice Address - Street 1:4595 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-2058
Practice Address - Country:US
Practice Address - Phone:904-448-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-04
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist