Healthcare Provider Details

I. General information

NPI: 1063006583
Provider Name (Legal Business Name): KATHERINE STICKNEY MT-BC, NMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2021
Last Update Date: 02/24/2021
Certification Date: 02/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 LAKE ST # LL65
OAK PARK IL
60301-1015
US

IV. Provider business mailing address

547 BROOKSIDE DR APT F
WESTMONT IL
60559-2727
US

V. Phone/Fax

Practice location:
  • Phone: 708-620-2373
  • Fax:
Mailing address:
  • Phone: 207-838-4401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number15974
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: