Provider Demographics
NPI:1073107132
Name:HICKMAN, LARRY
Entity Type:Individual
Prefix:
First Name:LARRY
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:PO BOX 5715
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-0715
Mailing Address - Country:US
Mailing Address - Phone:510-467-4250
Mailing Address - Fax:510-259-9090
Practice Address - Street 1:11 EMBARCADERO W STE 136
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94607-4500
Practice Address - Country:US
Practice Address - Phone:510-467-4250
Practice Address - Fax:510-259-9090
Is Sole Proprietor?:No
Enumeration Date:2021-03-01
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor