Provider Demographics
NPI:1487237533
Name:BICKERT, LISA ANN (PEER SUPPORT SPECIAL)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:BICKERT
Suffix:
Gender:F
Credentials:PEER SUPPORT SPECIAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-6048
Mailing Address - Country:US
Mailing Address - Phone:541-887-7974
Mailing Address - Fax:
Practice Address - Street 1:422 MAIN ST
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-6048
Practice Address - Country:US
Practice Address - Phone:541-887-7974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-05
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
OR21-CRM-597175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500803626Medicaid