Provider Demographics
NPI:1770211641
Name:HICKMAN, BLAKE LAUREN (ASW)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:LAUREN
Last Name:HICKMAN
Suffix:
Gender:F
Credentials:ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4525 VALLEY WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521
Mailing Address - Country:US
Mailing Address - Phone:225-270-1333
Mailing Address - Fax:
Practice Address - Street 1:720 WOOD STREET
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501
Practice Address - Country:US
Practice Address - Phone:707-572-8566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-09
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA117308104100000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker