Provider Demographics
NPI:1952811317
Name:HICKMAN, SHAVONDA M
Entity Type:Individual
Prefix:
First Name:SHAVONDA
Middle Name:M
Last Name:HICKMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5030 BROADWAY STE 201
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10034-1615
Mailing Address - Country:US
Mailing Address - Phone:212-795-9888
Mailing Address - Fax:
Practice Address - Street 1:5030 BROADWAY STE 201
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10034-1615
Practice Address - Country:US
Practice Address - Phone:212-795-9888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-11
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY099556-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker