Provider Demographics
NPI:1730960261
Name:KICKERY, DIANA (LMSW)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:KICKERY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1639 WINDSONG FOREST RD
Mailing Address - Street 2:
Mailing Address - City:CLOVER
Mailing Address - State:SC
Mailing Address - Zip Code:29710-9410
Mailing Address - Country:US
Mailing Address - Phone:803-627-0249
Mailing Address - Fax:
Practice Address - Street 1:1639 WINDSONG FOREST RD
Practice Address - Street 2:
Practice Address - City:CLOVER
Practice Address - State:SC
Practice Address - Zip Code:29710-9410
Practice Address - Country:US
Practice Address - Phone:803-627-0249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-10
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16396104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker