Provider Demographics
NPI:1881191658
Name:HICKNER, STEPHEN JAMES (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:JAMES
Last Name:HICKNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ALLENDALE HEALTH CENTER
Mailing Address - Street 2:4830 BECKER DRIVE
Mailing Address - City:ALLENDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49401
Mailing Address - Country:US
Mailing Address - Phone:616-252-3900
Mailing Address - Fax:
Practice Address - Street 1:ALLENDALE HEALTH CENTER
Practice Address - Street 2:4830 BECKER DRIVE
Practice Address - City:ALLENDALE
Practice Address - State:MI
Practice Address - Zip Code:49401
Practice Address - Country:US
Practice Address - Phone:616-252-3900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-09
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI43015040532084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program