Provider Demographics
NPI:1306288246
Name:HICKSON, KENDALL RAYE
Entity type:Individual
Prefix:
First Name:KENDALL
Middle Name:RAYE
Last Name:HICKSON
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 1:687 CHESHIRE AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-5060
Mailing Address - Country:US
Mailing Address - Phone:541-762-4556
Mailing Address - Fax:541-684-4156
Practice Address - Street 1:687 CHESHIRE AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402-5060
Practice Address - Country:US
Practice Address - Phone:541-684-4172
Practice Address - Fax:541-684-4156
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-19
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
16-05-22101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500661497Medicaid