1043373186 NPI number — MS. BRENDA L. GILMORE-HICKS

Table of content: MS. BRENDA L. GILMORE-HICKS (NPI 1043373186)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043373186 NPI number — MS. BRENDA L. GILMORE-HICKS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GILMORE-HICKS
Provider First Name:
BRENDA
Provider Middle Name:
L.
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GILMORE-HICKS
Provider Other First Name:
BRENDA
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1043373186
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4423 PELICAN PT
Provider Second Line Business Mailing Address:
NONE
Provider Business Mailing Address City Name:
PORTSMOUTH
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23703-5369
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-483-4255
Provider Business Mailing Address Fax Number:
757-466-0947

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 N CENTER DR BLDG 3
Provider Second Line Business Practice Location Address:
124
Provider Business Practice Location Address City Name:
NORFOLK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23502-4004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-227-3072
Provider Business Practice Location Address Fax Number:
757-227-3212
Provider Enumeration Date:
12/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  0904004800 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 010259223 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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