Basic Information
| Provider Information | |||||||||
| NPI: | 1306288246 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HICKSON | ||||||||
| FirstName: | KENDALL | ||||||||
| MiddleName: | RAYE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 687 CHESHIRE AVE | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974025060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417624556 | ||||||||
| FaxNumber: | 5416844156 | ||||||||
| Practice Location | |||||||||
| Address1: | 687 CHESHIRE AVE | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974025060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416844172 | ||||||||
| FaxNumber: | 5416844156 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2013 | ||||||||
| LastUpdateDate: | 04/09/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 16-05-22 | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 500661497 | 05 | OR | MEDICAID |