Basic Information
| Provider Information | |||||||||
| NPI: | 1063839645 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANSICKLE | ||||||||
| FirstName: | HILARY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA, TLLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HOLLERBACK | ||||||||
| OtherFirstName: | HILARY | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3400 S WASHINGTON RD | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486014958 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897551702 | ||||||||
| FaxNumber: | 9897551401 | ||||||||
| Practice Location | |||||||||
| Address1: | 3500 S WASHINGTON RD | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486014958 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897551072 | ||||||||
| FaxNumber: | 9897551401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2014 | ||||||||
| LastUpdateDate: | 03/21/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 6301015855 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.