Healthcare Provider Details

I. General information

NPI: 1578952289
Provider Name (Legal Business Name): COLTEN YOUNG SICARD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: ERIC MICHAEL SICARD

II. Dates (important events)

Enumeration Date: 01/19/2015
Last Update Date: 09/13/2026
Certification Date: 09/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 N 6TH E
MOUNTAIN HOME ID
83647-2208
US

IV. Provider business mailing address

930 N 6TH E
MOUNTAIN HOME ID
83647-2208
US

V. Phone/Fax

Practice location:
  • Phone: 406-303-1882
  • Fax:
Mailing address:
  • Phone: 406-303-1882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8861317
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number104015
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: