Provider Demographics
NPI:1750125589
Name:HICKMAN, MICHELLE
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:HICKMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:39 HOPKINS RD
Mailing Address - Street 2:
Mailing Address - City:ASHFORD
Mailing Address - State:AL
Mailing Address - Zip Code:36312-2535
Mailing Address - Country:US
Mailing Address - Phone:706-238-0201
Mailing Address - Fax:
Practice Address - Street 1:1936 ROSS CLARK CIR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-5750
Practice Address - Country:US
Practice Address - Phone:334-709-4042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALRBT-24-353803106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician