Provider Demographics
NPI:1871269118
Name:HICKERSON, AMBER ALEXIS
Entity Type:Individual
Prefix:MS
First Name:AMBER
Middle Name:ALEXIS
Last Name:HICKERSON
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 1:499 ROBINSON DR
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92782-0909
Mailing Address - Country:US
Mailing Address - Phone:909-553-8049
Mailing Address - Fax:
Practice Address - Street 1:499 ROBINSON DR
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92782-0909
Practice Address - Country:US
Practice Address - Phone:909-553-8049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician