Provider Demographics
NPI:1972543569
Name:HICKMAN, JOHN WILLIAM (PHD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WILLIAM
Last Name:HICKMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3150 E 41ST ST
Mailing Address - Street 2:STE 107
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-3717
Mailing Address - Country:US
Mailing Address - Phone:918-742-1136
Mailing Address - Fax:918-742-1183
Practice Address - Street 1:3150 E 41ST ST
Practice Address - Street 2:STE 107
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-3717
Practice Address - Country:US
Practice Address - Phone:918-742-1136
Practice Address - Fax:918-742-1183
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK193103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK731097671OtherTIN