Provider Demographics
NPI:1568789758
Name:HICKMAN, MARSHALL D (LPC)
Entity Type:Individual
Prefix:
First Name:MARSHALL
Middle Name:D
Last Name:HICKMAN
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 SOUTH INDUSTRY WAY
Mailing Address - Street 2:SUITE 45
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-922-2207
Mailing Address - Fax:
Practice Address - Street 1:609 S INDUSTRY WAY
Practice Address - Street 2:SUITE 45
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-922-2207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-27
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-4438101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional