Healthcare Provider Details

I. General information

NPI: 1144707753
Provider Name (Legal Business Name): MATTHEW HICKMAN RBT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2018
Last Update Date: 07/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 3RD ST SUITE AB
NEPTUNE BEACH FL
32266
US

IV. Provider business mailing address

2111 FORDHAM CIR N
JACKSONVILLE FL
32217-9121
US

V. Phone/Fax

Practice location:
  • Phone: 904-701-2926
  • Fax:
Mailing address:
  • Phone: 912-667-9007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-18-61519
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: