Healthcare Provider Details

I. General information

NPI: 1609768936
Provider Name (Legal Business Name): COREY HICKENBOTTOM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2025
Last Update Date: 07/21/2025
Certification Date: 07/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 W MAIN ST
OTTUMWA IA
52501-2523
US

IV. Provider business mailing address

403 W BROADWAY AVE
FAIRFIELD IA
52556-3234
US

V. Phone/Fax

Practice location:
  • Phone: 641-683-6747
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: