Heidi Kathleen Hicinbothom

Primary specialty

Peer SpecialistTaxonomy code 175T00000X

License

THW000001683 Issued in OR

Practice address

9605 Grand Ronde Rd
Grand Ronde, OR 97347-9712

Phone

(503) 879-2026

NPI assigned

Aug 18, 2017

Last updated

Dec 2, 2021By the provider in NPPES

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Interoperability endpoints

• Direct secure messaging: heidi.hiconbothom.p1@direct.grandronde.nextgenshare.com

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1503014400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1638403200000",
    "number": "1023534252",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "9605 GRAND RONDE RD",
            "city": "GRAND RONDE",
            "state": "OR",
            "postal_code": "973479712",
            "telephone_number": "503-879-2002"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "9605 GRAND RONDE RD",
            "city": "GRAND RONDE",
            "state": "OR",
            "postal_code": "973479712",
            "telephone_number": "503-879-2026"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "HICINBOTHOM",
        "first_name": "HEIDI",
        "middle_name": "KATHLEEN",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2017-08-18",
        "last_updated": "2021-12-02",
        "certification_date": "2021-12-02",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YA0400X",
            "taxonomy_group": "",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": "OR",
            "license": "T-21-874",
            "primary": false
        },
        {
            "code": "175T00000X",
            "taxonomy_group": "",
            "desc": "Peer Specialist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "175T00000X",
            "taxonomy_group": "",
            "desc": "Peer Specialist",
            "state": "OR",
            "license": "THW000001683",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "500753908",
            "state": "OR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Taylor Ann Gustafson
• Laura L Hale, DDS
• Traci Diane Hamilton
• Tricia Raye Hayden, APRN
• Michael Henry, PWS
• Mackenzie Hosley, RDH
• Linda 'Lynn' Michelle House, LPN
• Becky Ann Johnson, LD
• Jeanette Marie Kaschmitter, BA / MS
• Stephanie King, CHW

• Peer Specialist in Grand Ronde, OR
• Providers in Grand Ronde, OR by specialty
• Peer Specialist in Oregon

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 2, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.