Provider Demographics
NPI:1083890974
Name:HICKERSON, AMANDA (LPC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:HICKERSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:TALTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2202 EXECUTIVE DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-6604
Mailing Address - Country:US
Mailing Address - Phone:757-827-7707
Mailing Address - Fax:757-838-2573
Practice Address - Street 1:2202 EXECUTIVE DR
Practice Address - Street 2:SUITE C
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-6604
Practice Address - Country:US
Practice Address - Phone:757-827-7707
Practice Address - Fax:757-838-2573
Is Sole Proprietor?:No
Enumeration Date:2008-01-10
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701004243101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health