Provider Demographics
NPI:1316106768
Name:HICKERSON, SUSAN CORRELL (LPC, LPCS, LCAS)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:CORRELL
Last Name:HICKERSON
Suffix:
Gender:F
Credentials:LPC, LPCS, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 DAVID BIDDLE TRL
Mailing Address - Street 2:
Mailing Address - City:WEAVERVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28787-9736
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:58 DAVID BIDDLE TRL
Practice Address - Street 2:
Practice Address - City:WEAVERVILLE
Practice Address - State:NC
Practice Address - Zip Code:28787-9736
Practice Address - Country:US
Practice Address - Phone:828-658-0561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-02
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4269101YM0800X, 101YP2500X, 101Y00000X
NC20689101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC12345678Medicaid