Provider Demographics
NPI:1225697279
Name:PEREA-HICKAM, BRANDON A (PHD, BCBA, MFTC, ADD)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:A
Last Name:PEREA-HICKAM
Suffix:
Gender:M
Credentials:PHD, BCBA, MFTC, ADD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:954 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-5424
Mailing Address - Country:US
Mailing Address - Phone:720-461-4874
Mailing Address - Fax:
Practice Address - Street 1:954 5TH AVE
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-5424
Practice Address - Country:US
Practice Address - Phone:720-461-4874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-12
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 106S00000X, 106H00000X
CO103K00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician