Provider Demographics
NPI:1548436611
Name:LICCIARDO, CARMEN (LCSW-R)
Entity type:Individual
Prefix:MR
First Name:CARMEN
Middle Name:
Last Name:LICCIARDO
Suffix:
Gender:M
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 YELLOWBANK RD
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-8614
Mailing Address - Country:US
Mailing Address - Phone:732-245-9364
Mailing Address - Fax:
Practice Address - Street 1:16 PENN PLZ
Practice Address - Street 2:NEW YORKER HOTEL SUITE 544
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-1809
Practice Address - Country:US
Practice Address - Phone:732-245-9364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-07
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0155451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical