Provider Demographics
NPI:1972133270
Name:HICKEY, LISA MARIE (PRSS)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:HICKEY
Suffix:
Gender:F
Credentials:PRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2004 RUNNING BROOK LN
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-6778
Mailing Address - Country:US
Mailing Address - Phone:832-226-3265
Mailing Address - Fax:
Practice Address - Street 1:2004 RUNNING BROOK LN
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-6778
Practice Address - Country:US
Practice Address - Phone:832-226-3265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-25
Last Update Date:2020-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1873-0120175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty