Individual
BARBARA TERESA LICZNERSKI
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
826 WASHINGTON ST, SUITE 104, WATERTOWN, NY 13601-4065
(315) 786-1500
(315) 786-2074
Mailing address
826 WASHINGTON ST, SUITE 104, WATERTOWN, NY 13601-4065
(315) 786-1500
(315) 786-2074
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
187504-1
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
01563780
—
NY
01
—
070012711
RAILROAD MEDICARE
NY
01
—
AA0167
GROUP NUMBER
NY
Enumeration date
03/15/2006
Last updated
07/08/2007
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