Provider Demographics
NPI:1730604109
Name:LICKENBROCK, AMY ELIZABETH (MHS, CF-SLP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:ELIZABETH
Last Name:LICKENBROCK
Suffix:
Gender:F
Credentials:MHS, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2921 S 18TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63118-1710
Mailing Address - Country:US
Mailing Address - Phone:314-707-7506
Mailing Address - Fax:
Practice Address - Street 1:1251 TURTLE CREEK DR
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-5948
Practice Address - Country:US
Practice Address - Phone:636-379-0300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-07
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017026191235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist