Provider Demographics
NPI:1063244309
Name:HICKMAN, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:HICKMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2195 LARKSPUR LN STE 100B
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96002-0629
Mailing Address - Country:US
Mailing Address - Phone:530-338-0087
Mailing Address - Fax:
Practice Address - Street 1:2195 LARKSPUR LN STE 100B
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-0629
Practice Address - Country:US
Practice Address - Phone:530-338-0087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-15
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA139309101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health