Provider Demographics
NPI:1518497403
Name:HICKMAN, DOMINIQUE LEEANN (LCSW)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:LEEANN
Last Name:HICKMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 MEADOWOOD ST APT E
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27409-2357
Mailing Address - Country:US
Mailing Address - Phone:336-493-9875
Mailing Address - Fax:
Practice Address - Street 1:501 E GREEN DR
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27260
Practice Address - Country:US
Practice Address - Phone:336-641-7654
Practice Address - Fax:336-641-3210
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-14
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0116311041C0700X
NCC0123681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical