Provider Demographics
NPI:1699865352
Name:SICHMAN, TERESA
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:SICHMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:452 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-2815
Mailing Address - Country:US
Mailing Address - Phone:937-376-8700
Mailing Address - Fax:937-376-8725
Practice Address - Street 1:452 W MARKET ST
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-2815
Practice Address - Country:US
Practice Address - Phone:937-376-8700
Practice Address - Fax:937-376-8725
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS0500300101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHSISW33381Medicare UPIN