Provider Demographics
NPI:1508291311
Name:STICKLER, KEN
Entity Type:Individual
Prefix:
First Name:KEN
Middle Name:
Last Name:STICKLER
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 1:715 SW RAMSEY AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-5500
Mailing Address - Country:US
Mailing Address - Phone:541-474-5579
Mailing Address - Fax:
Practice Address - Street 1:1750 NEBRASKA AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5700
Practice Address - Country:US
Practice Address - Phone:541-474-5579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-11
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health