Provider Demographics
NPI:1063440618
Name:HICKMON, DEBRA A (CACD III)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:A
Last Name:HICKMON
Suffix:
Gender:F
Credentials:CACD III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W ALONA LN
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:WI
Mailing Address - Zip Code:53813-2202
Mailing Address - Country:US
Mailing Address - Phone:608-723-6357
Mailing Address - Fax:608-723-4417
Practice Address - Street 1:200 W ALONA LN
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:WI
Practice Address - Zip Code:53813-2202
Practice Address - Country:US
Practice Address - Phone:608-723-6357
Practice Address - Fax:608-723-4417
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1956101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11103OtherDEAN HEALTH PLANS
WI39396200OtherHIRSP
WI39396200Medicaid
WI39396200OtherHIRSP