Provider Demographics
NPI:1306382924
Name:HICKEY, BROOKE
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:HICKEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 STATE ROUTE 545
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44805-8934
Mailing Address - Country:US
Mailing Address - Phone:419-685-2525
Mailing Address - Fax:
Practice Address - Street 1:1102 STATE ROUTE 545
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OH
Practice Address - Zip Code:44805-8934
Practice Address - Country:US
Practice Address - Phone:419-685-2525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-07
Last Update Date:2017-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHXXXXXXXXX405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional