Provider Demographics
NPI:1447874193
Name:LICHT, DANIELLE NICOLE (OD)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:NICOLE
Last Name:LICHT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:868 WALKER AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610-2033
Mailing Address - Country:US
Mailing Address - Phone:925-413-3110
Mailing Address - Fax:
Practice Address - Street 1:868 WALKER AVE APT 1
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-2033
Practice Address - Country:US
Practice Address - Phone:925-413-3110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-28
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34566152W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty