Provider Demographics
NPI:1144513284
Name:LICON, VALJEAN EUGENE (LMFT)
Entity type:Individual
Prefix:MR
First Name:VALJEAN
Middle Name:EUGENE
Last Name:LICON
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 GOOSEBERRY DR
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89523-9612
Mailing Address - Country:US
Mailing Address - Phone:775-240-1818
Mailing Address - Fax:
Practice Address - Street 1:1005 FOREST ST
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-2706
Practice Address - Country:US
Practice Address - Phone:775-329-4582
Practice Address - Fax:775-329-9943
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-23
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVCP0124101YP2500X
NV01375106H00000X, 106H00000X
NV01937-I101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV114513284Medicaid