Provider Demographics
NPI:1255479598
Name:HICKERSON, LEEEVA L (BS)
Entity Type:Individual
Prefix:
First Name:LEEEVA
Middle Name:L
Last Name:HICKERSON
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 NAVY RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:MILLINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38053-1914
Mailing Address - Country:US
Mailing Address - Phone:901-504-9915
Mailing Address - Fax:901-504-9915
Practice Address - Street 1:4800 NAVY RD
Practice Address - Street 2:SUITE 3
Practice Address - City:MILLINGTON
Practice Address - State:TN
Practice Address - Zip Code:38053-1914
Practice Address - Country:US
Practice Address - Phone:901-504-9915
Practice Address - Fax:901-504-9915
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No171W00000XOther Service ProvidersContractor