Provider Demographics
NPI:1053287615
Name:LICON, ANGIE D
Entity type:Individual
Prefix:
First Name:ANGIE
Middle Name:D
Last Name:LICON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 LAKE CARNEGIE CT
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78041-1984
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3922 WISEMAN BLVD UNIT 4
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-1668
Practice Address - Country:US
Practice Address - Phone:210-981-6836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-13
Last Update Date:2025-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician