Provider Demographics
NPI:1932250560
Name:MCKIBBEN, CAROL R (MSW)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:R
Last Name:MCKIBBEN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:MRS
Other - First Name:CAROL
Other - Middle Name:R
Other - Last Name:STICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:621 W. MADRONE ST
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-3090
Mailing Address - Country:US
Mailing Address - Phone:541-440-3532
Mailing Address - Fax:541-440-3554
Practice Address - Street 1:621 W. MADRONE ST
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-3090
Practice Address - Country:US
Practice Address - Phone:541-440-3532
Practice Address - Fax:541-440-3554
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
ORCSWA A3182101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500660589Medicaid