Provider Demographics
NPI:1871263053
Name:HICKMAN, RODERICK J
Entity Type:Individual
Prefix:
First Name:RODERICK
Middle Name:J
Last Name:HICKMAN
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 1:1025 ATLANTIC AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501
Mailing Address - Country:US
Mailing Address - Phone:916-698-3543
Mailing Address - Fax:
Practice Address - Street 1:1025 ATLANTIC AVE.
Practice Address - Street 2:STE 101
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501
Practice Address - Country:US
Practice Address - Phone:916-698-3543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-17
Last Update Date:2021-10-07
Deactivation Date:2021-09-17
Deactivation Code:
Reactivation Date:2021-10-05
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician