Provider Demographics
NPI:1538425137
Name:LICCIARDI, KANDACE R (MD)
Entity type:Individual
Prefix:
First Name:KANDACE
Middle Name:R
Last Name:LICCIARDI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KANDACE
Other - Middle Name:R
Other - Last Name:MCALISTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:392 SEGUINE AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309-3906
Mailing Address - Country:US
Mailing Address - Phone:718-226-2275
Mailing Address - Fax:
Practice Address - Street 1:392 SEGUINE AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10309-3906
Practice Address - Country:US
Practice Address - Phone:718-226-2275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-09
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2850002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry