Provider Demographics
NPI:1043850936
Name:HICKMAN, QUINELLE (LMFT)
Entity type:Individual
Prefix:MS
First Name:QUINELLE
Middle Name:
Last Name:HICKMAN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 WALL ST STE 139
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10005-4301
Mailing Address - Country:US
Mailing Address - Phone:646-883-0758
Mailing Address - Fax:
Practice Address - Street 1:920 METCALF AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10473-4007
Practice Address - Country:US
Practice Address - Phone:646-883-0758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-09
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001647106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist