Provider Demographics
NPI:1922582519
Name:DIZICK, MONICA (CADC I)
Entity Type:Individual
Prefix:MS
First Name:MONICA
Middle Name:
Last Name:DIZICK
Suffix:
Gender:F
Credentials:CADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1435 NE 4TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-4268
Mailing Address - Country:US
Mailing Address - Phone:541-306-4446
Mailing Address - Fax:541-550-2011
Practice Address - Street 1:1435 NE 4TH ST STE B
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4268
Practice Address - Country:US
Practice Address - Phone:541-306-4446
Practice Address - Fax:541-550-2011
Is Sole Proprietor?:No
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR18-06-06OtherSTATE OF OREGON ACCBO