Healthcare Provider Details

I. General information

NPI: 1679078836
Provider Name (Legal Business Name): INTEGRATED CARE OF GREATER HICKORY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2018
Last Update Date: 06/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

741 5TH ST SW
HICKORY NC
28602
US

IV. Provider business mailing address

425 7TH AVE SW
HICKORY NC
28602-3237
US

V. Phone/Fax

Practice location:
  • Phone: 828-322-5915
  • Fax: 828-345-0387
Mailing address:
  • Phone: 828-322-5915
  • Fax: 828-345-0387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. DOUGLAS DAVID BLAKEMAN
Title or Position: CHIEF ADMINISTRATION OFFICER
Credential: RMA
Phone: 828-322-5915