Provider Demographics
NPI:1881822716
Name:HICKMAN, BLAINE REUBEN
Entity Type:Individual
Prefix:MR
First Name:BLAINE
Middle Name:REUBEN
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 1:930 W HILL FIELD RD
Mailing Address - Street 2:#A
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-4662
Mailing Address - Country:US
Mailing Address - Phone:801-336-3040
Mailing Address - Fax:801-336-3041
Practice Address - Street 1:930 W HILL FIELD RD
Practice Address - Street 2:#A
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-4662
Practice Address - Country:US
Practice Address - Phone:801-336-3040
Practice Address - Fax:801-336-3041
Is Sole Proprietor?:No
Enumeration Date:2009-06-30
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical