Provider Demographics
NPI:1841605763
Name:HICKMAN, TATYANA
Entity Type:Individual
Prefix:
First Name:TATYANA
Middle Name:
Last Name:HICKMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2060 DAN PROCTOR DR
Mailing Address - Street 2:SUITE 3300
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-3894
Mailing Address - Country:US
Mailing Address - Phone:912-882-3800
Mailing Address - Fax:912-882-3303
Practice Address - Street 1:2060 DAN PROCTOR DR
Practice Address - Street 2:SUITE 3300
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-3894
Practice Address - Country:US
Practice Address - Phone:912-882-3800
Practice Address - Fax:912-882-3303
Is Sole Proprietor?:No
Enumeration Date:2014-06-30
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW0000104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker