Provider Demographics
NPI:1114595857
Name:HICKEY, SHANNON (DPT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:HICKEY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 PARKER ST APT D106
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-2375
Mailing Address - Country:US
Mailing Address - Phone:508-468-7682
Mailing Address - Fax:
Practice Address - Street 1:15 RIVERSIDE AVENUE
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010
Practice Address - Country:US
Practice Address - Phone:508-468-7682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-17
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0123092251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic