Provider Information for 1245724020
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KATHRYN LYNNE HICKOK MANNEBACH LMSW
Sex: Female
NPI: 1245724020
Last Updated: 2023-06-22
Certification Date: 2023-06-22
Certification Date: 2023-06-22
Details
| Name | Value | ||||||||
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| NPI | 1245724020 | ||||||||
| Enumeration Date | 2018-06-15 | ||||||||
| NPI Type | NPI-1 Individual | ||||||||
| Sole Proprietor | NO | ||||||||
| Status | Active | ||||||||
| Mailing Address | 75 DIAMOND AVE NE GRAND RAPIDS, MI 49503-3602 United States Phone: 269-330-4963 | Fax: | ||||||||
| Primary Practice Address | 300 68TH ST SE GRAND RAPIDS, MI 49548-6927 United States Phone: 269-330-4963 | Fax: | ||||||||
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