Provider Demographics
NPI:1063006583
Name:STICKNEY, KATHERINE (MT-BC, NMT)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:STICKNEY
Suffix:
Gender:F
Credentials:MT-BC, NMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:547 BROOKSIDE DR APT F
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-2727
Mailing Address - Country:US
Mailing Address - Phone:207-838-4401
Mailing Address - Fax:
Practice Address - Street 1:1100 LAKE ST # LL65
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1015
Practice Address - Country:US
Practice Address - Phone:708-620-2373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-24
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL15974225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist