Provider Demographics
NPI:1245695147
Name:SICKENGER, AMANDA MAE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MAE
Last Name:SICKENGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 CLIFFSIDE DR APT 207
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-4341
Mailing Address - Country:US
Mailing Address - Phone:505-386-6211
Mailing Address - Fax:
Practice Address - Street 1:1001 W BROADWAY
Practice Address - Street 2:SUITE D
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5638
Practice Address - Country:US
Practice Address - Phone:505-326-8695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-18
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM44933Medicaid