Provider Demographics
NPI:1558957688
Name:HICKMAN, KYLE ELMO (LCSW)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:ELMO
Last Name:HICKMAN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:338 W 300 N STE 6
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:UT
Mailing Address - Zip Code:84318-4044
Mailing Address - Country:US
Mailing Address - Phone:435-241-7105
Mailing Address - Fax:
Practice Address - Street 1:338 W 300 N STE 6
Practice Address - Street 2:
Practice Address - City:HYDE PARK
Practice Address - State:UT
Practice Address - Zip Code:84318-4044
Practice Address - Country:US
Practice Address - Phone:435-241-7105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-13
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11767393-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical