Provider Demographics
NPI:1558096180
Name:HICKMAN, CRYSTAL (LMT)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:HICKMAN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 BEEHIVE PL APT D
Mailing Address - Street 2:
Mailing Address - City:COCKEYSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21030-3738
Mailing Address - Country:US
Mailing Address - Phone:571-394-1124
Mailing Address - Fax:
Practice Address - Street 1:22 W PADONIA RD STE B229
Practice Address - Street 2:
Practice Address - City:TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-2247
Practice Address - Country:US
Practice Address - Phone:443-574-5985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-18
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM06019225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist