Provider Demographics
NPI:1699203752
Name:HICKMAN, MICHAEL LEE (CDCA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LEE
Last Name:HICKMAN
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 AUERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:45612-9634
Mailing Address - Country:US
Mailing Address - Phone:740-600-4630
Mailing Address - Fax:
Practice Address - Street 1:14574 US HIGHWAY 23
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:OH
Practice Address - Zip Code:45690-9373
Practice Address - Country:US
Practice Address - Phone:740-912-9093
Practice Address - Fax:740-947-6917
Is Sole Proprietor?:No
Enumeration Date:2017-06-01
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH162832101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)