Provider Demographics
NPI:1538515614
Name:HICKENBOTTOM, KORTNEY
Entity Type:Individual
Prefix:
First Name:KORTNEY
Middle Name:
Last Name:HICKENBOTTOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2714 CANAL ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-5548
Mailing Address - Country:US
Mailing Address - Phone:504-570-6120
Mailing Address - Fax:504-570-6121
Practice Address - Street 1:2714 CANAL ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-5548
Practice Address - Country:US
Practice Address - Phone:504-570-6120
Practice Address - Fax:504-570-6121
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-09
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health