1003958992 NPI number — MS. MARY HASTY HICKOK LICSW

Table of content: MRS. BROOKE THOMSON LPN (NPI 1558977983)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003958992 NPI number — MS. MARY HASTY HICKOK LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HICKOK
Provider First Name:
MARY HASTY
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HICKOK
Provider Other First Name:
HASTY
Provider Other Middle Name:
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1003958992
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/29/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
62 SOUTH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLIAMSBURG
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01096-9726
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
413-348-8275
Provider Business Mailing Address Fax Number:
413-582-6956

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
62 SOUTH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLIAMSBURG
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01096-9726
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
413-348-8275
Provider Business Practice Location Address Fax Number:
413-582-6956
Provider Enumeration Date:
02/14/2007

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:  103962 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1893076 . This is a "BC" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 249652 . This is a "MAGELLAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1893076 . This is a "MBHP" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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