Provider Demographics
NPI:1518224369
Name:STICKNEY, ANDRE L (AAC)
Entity Type:Individual
Prefix:MR
First Name:ANDRE
Middle Name:L
Last Name:STICKNEY
Suffix:
Gender:M
Credentials:AAC
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 1845
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98668-1845
Mailing Address - Country:US
Mailing Address - Phone:390-397-8484
Mailing Address - Fax:360-397-8494
Practice Address - Street 1:1601 E 4TH PLAIN BLVD
Practice Address - Street 2:BLDG 17 STE B222
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-3753
Practice Address - Country:US
Practice Address - Phone:390-397-8484
Practice Address - Fax:360-397-8494
Is Sole Proprietor?:No
Enumeration Date:2012-04-18
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR103K00000X103K00000X
WACG60410111101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR164936Medicaid
R0000WDBCHOtherMEDICARE GROUP