Provider Demographics
NPI:1619188588
Name:STICE, BOB G (LPCC)
Entity Type:Individual
Prefix:
First Name:BOB
Middle Name:G
Last Name:STICE
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 CARLISLE BLVD NE
Mailing Address - Street 2:SUITE 222
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-1600
Mailing Address - Country:US
Mailing Address - Phone:505-889-4583
Mailing Address - Fax:505-889-4598
Practice Address - Street 1:3200 CARLISLE BLVD NE
Practice Address - Street 2:SUITE 222
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-1600
Practice Address - Country:US
Practice Address - Phone:505-889-4583
Practice Address - Fax:505-889-4598
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3329101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional