Basic Information
| Provider Information | |||||||||
| NPI: | 1669522769 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LICATA | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6200 COTTAGE CREEK RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHPORT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284612983 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5712161272 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 120 COASTAL HORIZONS DR | ||||||||
| Address2: | |||||||||
| City: | SHALLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284706094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107544515 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 08/12/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 0101027066 | VA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 2014-01510 | NC | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.