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General NPI Number Information
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NPI Number | 1518580570
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Entity Type | Individual
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Provider Name | CORY JOSEPH BICKHAM LCDC
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Gender | Male
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Dates
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Enumeration Date | 05/26/2020
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Last Update Date | 05/26/2020
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Provider Practice Location Address
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Address Line | 11503 PARSONS RD
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City | MANOR
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State | TX
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Zip | 78653-5220
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Country | US
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Telephone | 512-278-4923
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Fax |
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Provider Business Mailing Address
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Address Line | 6903 PINTO CV
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City | LAGO VISTA
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State | TX
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Zip | 78645-4920
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Country | US
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Telephone | 225-936-5954
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 15005
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License Number State | TX
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