Basic Information
| Provider Information | |||||||||
| NPI: | 1346713435 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HICKSON | ||||||||
| FirstName: | TIANA | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 742 CATA RD | ||||||||
| Address2: | |||||||||
| City: | CUMBERLAND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 230403003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4348257665 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 941 GLENWOOD STATION LN STE 204 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229015719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349955367 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2019 | ||||||||
| LastUpdateDate: | 05/17/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | VA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.