Provider Demographics
NPI:1679886279
Name:HICKENBOTTOM, ANGELA NICOLE (LMFT)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:NICOLE
Last Name:HICKENBOTTOM
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 1ST ST
Mailing Address - Street 2:
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020-4733
Mailing Address - Country:US
Mailing Address - Phone:408-613-4055
Mailing Address - Fax:
Practice Address - Street 1:1215 1ST ST
Practice Address - Street 2:
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-4733
Practice Address - Country:US
Practice Address - Phone:408-613-4055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT102595106H00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist