Provider Demographics
NPI:1609190859
Name:HICKMAN, STEPHEN (LCDCIII)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:HICKMAN
Suffix:
Gender:M
Credentials:LCDCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:452 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-2815
Mailing Address - Country:US
Mailing Address - Phone:937-376-8700
Mailing Address - Fax:937-376-8204
Practice Address - Street 1:600 E DAYTON YELLOW SPRINGS RD
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-3995
Practice Address - Country:US
Practice Address - Phone:937-879-3400
Practice Address - Fax:937-376-8204
Is Sole Proprietor?:No
Enumeration Date:2010-03-17
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH011303101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)