Provider Demographics
NPI:1326677154
Name:HICKEY, SHAWN LAMON
Entity Type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:LAMON
Last Name:HICKEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 486
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-0486
Mailing Address - Country:US
Mailing Address - Phone:423-255-1023
Mailing Address - Fax:
Practice Address - Street 1:4240 SOUTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-5634
Practice Address - Country:US
Practice Address - Phone:800-472-1365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-03
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11001104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker