Provider Demographics
NPI:1205371978
Name:HICKSON, KELLIE
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:HICKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 CENTENNIAL LOOP STE A
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-7900
Mailing Address - Country:US
Mailing Address - Phone:541-393-0777
Mailing Address - Fax:541-687-9279
Practice Address - Street 1:1461 OAK ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-4007
Practice Address - Country:US
Practice Address - Phone:541-687-9741
Practice Address - Fax:541-687-9279
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-04
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM2800X
OR101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone