Basic Information
| Provider Information | |||||||||
| NPI: | 1124553466 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SICKENDICK | ||||||||
| FirstName: | TRICIA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRM | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1870 WESTCHESTER CT NW | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973041841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034095092 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 998 LIBRARY CT | ||||||||
| Address2: | |||||||||
| City: | OREGON CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970454041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036558401 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2017 | ||||||||
| LastUpdateDate: | 10/09/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | 17-CRM-069 | OR | N | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 17-CRM-069 | 01 | OR | CERTIFIED RECOVERY MENTOR | OTHER |