Basic Information
| Provider Information | |||||||||
| NPI: | 1023534252 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HICINBOTHOM | ||||||||
| FirstName: | HEIDI | ||||||||
| MiddleName: | KATHLEEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9605 GRAND RONDE RD | ||||||||
| Address2: | |||||||||
| City: | GRAND RONDE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973479712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038792002 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9605 GRAND RONDE RD | ||||||||
| Address2: | |||||||||
| City: | GRAND RONDE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973479712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038792026 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2017 | ||||||||
| LastUpdateDate: | 12/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | T-21-874 | OR | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 175T00000X | N | 175T00000X | THW000001683 | OR | Y |
ID Information
| ID | Type | State | Issuer | Description | 500753908 | 05 | OR | MEDICAID |