Provider Demographics
NPI:1689462822
Name:HICKMAN, TAMYRA (LSW)
Entity type:Individual
Prefix:
First Name:TAMYRA
Middle Name:
Last Name:HICKMAN
Suffix:
Gender:
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4315 S CHAMPLAIN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-5080
Mailing Address - Country:US
Mailing Address - Phone:312-523-7438
Mailing Address - Fax:
Practice Address - Street 1:3709 N KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-4503
Practice Address - Country:US
Practice Address - Phone:312-523-7438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-28
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.113824104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker