Provider Demographics
NPI:1740141530
Name:LICEA, TOMAS MIGUEL
Entity type:Individual
Prefix:
First Name:TOMAS
Middle Name:MIGUEL
Last Name:LICEA
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 1:3996 S HOBART BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90062-1123
Mailing Address - Country:US
Mailing Address - Phone:323-508-0155
Mailing Address - Fax:
Practice Address - Street 1:3996 S HOBART BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90062-1123
Practice Address - Country:US
Practice Address - Phone:323-508-0155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-11-20
Last Update Date:2025-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4DBEA91E63171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach