Provider Demographics
NPI:1710391628
Name:HICKMAN, KRISTA (MA, NCSP, SP408)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:HICKMAN
Suffix:
Gender:F
Credentials:MA, NCSP, SP408
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1858 BRANDIGEN LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43228-3883
Mailing Address - Country:US
Mailing Address - Phone:614-270-8910
Mailing Address - Fax:
Practice Address - Street 1:1605-A AIRPORT RD
Practice Address - Street 2:
Practice Address - City:NEW LEXINGTON
Practice Address - State:OH
Practice Address - Zip Code:43764-1407
Practice Address - Country:US
Practice Address - Phone:740-342-4133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-18
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP408103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool