Provider Demographics
NPI:1508070772
Name:SICE, BERNICE E (AA)
Entity Type:Individual
Prefix:MS
First Name:BERNICE
Middle Name:E
Last Name:SICE
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1437
Mailing Address - Street 2:CONNECTIONS, INC. ATTN BERNICE E. SICE
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87305-1437
Mailing Address - Country:US
Mailing Address - Phone:505-722-0641
Mailing Address - Fax:505-722-9870
Practice Address - Street 1:303 S 1ST ST
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-6211
Practice Address - Country:US
Practice Address - Phone:505-722-0641
Practice Address - Fax:505-722-9870
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3986101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)