Provider Demographics
NPI:1275139867
Name:CHICOINE, EDMOND B
Entity Type:Individual
Prefix:MR
First Name:EDMOND
Middle Name:B
Last Name:CHICOINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19995 HARTMANN RD
Mailing Address - Street 2:
Mailing Address - City:HIDDEN VALLEY LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95467-8366
Mailing Address - Country:US
Mailing Address - Phone:209-401-9687
Mailing Address - Fax:
Practice Address - Street 1:313 KENDAL ST STE B
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-3960
Practice Address - Country:US
Practice Address - Phone:707-330-7904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT108597106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist