Healthcare Provider Details

I. General information

NPI: 1518224369
Provider Name (Legal Business Name): ANDRE L STICKNEY AAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2012
Last Update Date: 05/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 E 4TH PLAIN BLVD BLDG 17 STE B222
VANCOUVER WA
98661-3753
US

IV. Provider business mailing address

PO BOX 1845
VANCOUVER WA
98668-1845
US

V. Phone/Fax

Practice location:
  • Phone: 390-397-8484
  • Fax: 360-397-8494
Mailing address:
  • Phone: 390-397-8484
  • Fax: 360-397-8494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCG60410111
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number103K00000X
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: