Provider Demographics
NPI:1104955202
Name:HICKERSON, BRANDY T (MED, PSYCHOLOGIST)
Entity type:Individual
Prefix:
First Name:BRANDY
Middle Name:T
Last Name:HICKERSON
Suffix:
Gender:F
Credentials:MED, PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 3 BOX 474
Mailing Address - Street 2:
Mailing Address - City:BROKEN BOW
Mailing Address - State:OK
Mailing Address - Zip Code:74728-9584
Mailing Address - Country:US
Mailing Address - Phone:580-212-2726
Mailing Address - Fax:
Practice Address - Street 1:17 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-4625
Practice Address - Country:US
Practice Address - Phone:580-286-5184
Practice Address - Fax:580-286-5185
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YP2500X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool