Healthcare Provider Details

I. General information

NPI: 1639716061
Provider Name (Legal Business Name): SHERRY ANN HICKMON BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2019
Last Update Date: 02/19/2021
Certification Date: 02/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 SOUTHERN BLVD
SAVANNAH GA
31405-7437
US

IV. Provider business mailing address

107 SOUTHERN BLVD
SAVANNAH GA
31405-7437
US

V. Phone/Fax

Practice location:
  • Phone: 800-844-1232
  • Fax:
Mailing address:
  • Phone: 800-844-1232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-21-47772
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0167254
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: