Provider Demographics
NPI:1396999181
Name:HICKMAN, STACEY DAWN (MA, LLPC)
Entity type:Individual
Prefix:MS
First Name:STACEY
Middle Name:DAWN
Last Name:HICKMAN
Suffix:
Gender:F
Credentials:MA, LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21261 KELLY RD
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-3125
Mailing Address - Country:US
Mailing Address - Phone:586-771-7253
Mailing Address - Fax:586-771-7142
Practice Address - Street 1:21261 KELLY RD
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-3125
Practice Address - Country:US
Practice Address - Phone:586-771-7253
Practice Address - Fax:586-771-7142
Is Sole Proprietor?:No
Enumeration Date:2008-11-06
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401010963101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional