Provider Demographics
NPI:1639446727
Name:LINCICOME, ANDREW JOHN (CDP)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:JOHN
Last Name:LINCICOME
Suffix:
Gender:M
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 112TH AVE NE
Mailing Address - Street 2:SUITE 150W
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-2993
Mailing Address - Country:US
Mailing Address - Phone:425-646-7279
Mailing Address - Fax:425-646-7499
Practice Address - Street 1:841 CENTRAL AVE N
Practice Address - Street 2:SUITE C-215
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-2016
Practice Address - Country:US
Practice Address - Phone:253-867-5344
Practice Address - Fax:253-867-5348
Is Sole Proprietor?:No
Enumeration Date:2011-11-17
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60215833101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)