Provider Demographics
NPI:1689269102
Name:HIBBLER, ERICK T
Entity Type:Individual
Prefix:
First Name:ERICK
Middle Name:T
Last Name:HIBBLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 689
Mailing Address - Street 2:
Mailing Address - City:RICHTON
Mailing Address - State:MS
Mailing Address - Zip Code:39476-0689
Mailing Address - Country:US
Mailing Address - Phone:601-408-0719
Mailing Address - Fax:
Practice Address - Street 1:411 OAK STREET
Practice Address - Street 2:
Practice Address - City:RICHTON
Practice Address - State:MS
Practice Address - Zip Code:39476-3947
Practice Address - Country:US
Practice Address - Phone:601-408-0719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSCDI-200101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty