Provider Demographics
NPI:1588332936
Name:RICKENBACHER, EILENE LAREE (SUDPT)
Entity type:Individual
Prefix:MRS
First Name:EILENE
Middle Name:LAREE
Last Name:RICKENBACHER
Suffix:
Gender:F
Credentials:SUDPT
Other - Prefix:MRS
Other - First Name:CRICKETT
Other - Middle Name:L
Other - Last Name:RICKENBACHER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:SUDPT
Mailing Address - Street 1:716 S CHASE ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-6122
Mailing Address - Country:US
Mailing Address - Phone:360-395-2976
Mailing Address - Fax:360-395-2977
Practice Address - Street 1:716 S CHASE ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-6122
Practice Address - Country:US
Practice Address - Phone:360-395-2976
Practice Address - Fax:360-395-2977
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60956969101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)