Provider Demographics
NPI:1356848782
Name:HICKEY, AMANDA M (LISW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:M
Last Name:HICKEY
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 SOUTH EDWIN C MOSES BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-3424
Mailing Address - Country:US
Mailing Address - Phone:937-734-8333
Mailing Address - Fax:
Practice Address - Street 1:601 SOUTH EDWIN C MOSES BLVD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-3424
Practice Address - Country:US
Practice Address - Phone:937-734-8333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-11
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.0900620104100000X
OHS0900620104100000X
OHI20023571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
261QM0801XOtherGROUP NPI