Basic Information
| Provider Information | |||||||||
| NPI: | 1972839272 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HICKEY | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | NICOLE | ||||||||
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| OtherLastName: | HICKEY | ||||||||
| OtherFirstName: | LISA | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1600 ALDERSGATE RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722056676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016610720 | ||||||||
| FaxNumber: | 5013257938 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 ALDERSGATE RD | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722057018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012170183 | ||||||||
| FaxNumber: | 5012179757 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2009 | ||||||||
| LastUpdateDate: | 03/14/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | PROVISIONAL | AR | N | Behavioral Health & Social Service Providers | Counselor | 1041C0700X | 6417-C | AR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.