Provider Demographics
NPI:1679590475
Name:VAN SICKLE, CONNIE JEANINE (LMFT)
Entity Type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:JEANINE
Last Name:VAN SICKLE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4929 BOYD DR
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-4917
Mailing Address - Country:US
Mailing Address - Phone:916-487-1898
Mailing Address - Fax:
Practice Address - Street 1:3201 FLORIN PERKINS RD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95826-3900
Practice Address - Country:US
Practice Address - Phone:916-875-0579
Practice Address - Fax:916-875-0578
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27202106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA27202Medicare ID - Type UnspecifiedMFT LICENSE