Provider Demographics
NPI:1518580570
Name:BICKHAM, CORY JOSEPH (LCDC)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:JOSEPH
Last Name:BICKHAM
Suffix:
Gender:M
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6903 PINTO CV
Mailing Address - Street 2:
Mailing Address - City:LAGO VISTA
Mailing Address - State:TX
Mailing Address - Zip Code:78645-4920
Mailing Address - Country:US
Mailing Address - Phone:225-936-5954
Mailing Address - Fax:
Practice Address - Street 1:11503 PARSONS RD
Practice Address - Street 2:
Practice Address - City:MANOR
Practice Address - State:TX
Practice Address - Zip Code:78653-5220
Practice Address - Country:US
Practice Address - Phone:512-278-4923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-26
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15005101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)