1679590475 NPI number — MS. CONNIE JEANINE VAN SICKLE LMFT

Table of content: MS. CONNIE JEANINE VAN SICKLE LMFT (NPI 1679590475)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679590475 NPI number — MS. CONNIE JEANINE VAN SICKLE LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN SICKLE
Provider First Name:
CONNIE
Provider Middle Name:
JEANINE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LMFT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679590475
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4929 BOYD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARMICHAEL
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95608-4917
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-487-1898
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3201 FLORIN PERKINS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95826-3900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-875-0579
Provider Business Practice Location Address Fax Number:
916-875-0578
Provider Enumeration Date:
07/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  27202 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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