Provider Demographics
NPI:1235648254
Name:HICKERSON, DARLENE (LCDC III)
Entity Type:Individual
Prefix:
First Name:DARLENE
Middle Name:
Last Name:HICKERSON
Suffix:
Gender:F
Credentials:LCDC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 WASHINGTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44113
Mailing Address - Country:US
Mailing Address - Phone:216-781-0550
Mailing Address - Fax:216-781-7501
Practice Address - Street 1:1302 WINSLOW AVENUE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44113
Practice Address - Country:US
Practice Address - Phone:216-727-2057
Practice Address - Fax:216-771-1563
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-21
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0.151168101YA0400X
OH161608101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0282029Medicaid
OH0.151168OtherOHIO CHEMICAL DEPENDENCY PROFESSIONALS BOARD