Provider Demographics
NPI:1942408331
Name:HICKSON, CORRINE LEE (PHD)
Entity type:Individual
Prefix:DR
First Name:CORRINE
Middle Name:LEE
Last Name:HICKSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MRS
Other - First Name:CORRINE
Other - Middle Name:L
Other - Last Name:HICKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:25550 HAWTHORNE BLVD
Mailing Address - Street 2:#316
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505
Mailing Address - Country:US
Mailing Address - Phone:310-375-8665
Mailing Address - Fax:310-375-8187
Practice Address - Street 1:25550 HAWTHORNE BLVD
Practice Address - Street 2:#316
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505
Practice Address - Country:US
Practice Address - Phone:310-375-8665
Practice Address - Fax:310-375-8187
Is Sole Proprietor?:No
Enumeration Date:2007-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17257103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist