Provider Demographics
NPI:1669022281
Name:HICKMAN, MATT (LCPC)
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:HICKMAN
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 W JEFFERSON ST STE 401
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3969
Mailing Address - Country:US
Mailing Address - Phone:309-431-1296
Mailing Address - Fax:
Practice Address - Street 1:207 W JEFFERSON ST STE 401
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3969
Practice Address - Country:US
Practice Address - Phone:309-431-1296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-16
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.013357101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional