Provider Demographics
NPI:1114002664
Name:SICKLER, JOHN GREGORY (LCSW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:GREGORY
Last Name:SICKLER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10595 SW LUCAS CT
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-8414
Mailing Address - Country:US
Mailing Address - Phone:503-307-4112
Mailing Address - Fax:
Practice Address - Street 1:511 SW 10TH AVE
Practice Address - Street 2:SUITE 614
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2732
Practice Address - Country:US
Practice Address - Phone:503-307-4112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR34931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR164936Medicaid
OR0000WDBCHMedicare ID - Type Unspecified