Provider Demographics
NPI:1043373186
Name:GILMORE-HICKS, BRENDA L
Entity Type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:L
Last Name:GILMORE-HICKS
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:BRENDA
Other - Middle Name:L
Other - Last Name:GILMORE-HICKS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:4423 PELICAN PT
Mailing Address - Street 2:NONE
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-5369
Mailing Address - Country:US
Mailing Address - Phone:757-483-4255
Mailing Address - Fax:757-466-0947
Practice Address - Street 1:400 N CENTER DR BLDG 3
Practice Address - Street 2:124
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-4004
Practice Address - Country:US
Practice Address - Phone:757-227-3072
Practice Address - Fax:757-227-3212
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040048001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010259223Medicaid