Provider Demographics
NPI:1588382709
Name:LICEA, CHRISTOPHER (DPT)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:LICEA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3280 WOODBRIAR LN
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32303-7563
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:160 RIVER BEND DR STE 104
Practice Address - Street 2:
Practice Address - City:GRANITE FALLS
Practice Address - State:NC
Practice Address - Zip Code:28630-9389
Practice Address - Country:US
Practice Address - Phone:828-212-5098
Practice Address - Fax:828-313-0376
Is Sole Proprietor?:No
Enumeration Date:2022-08-15
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT39209225100000X
NCP22816225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP22816OtherPT LICENSE