Provider Demographics
NPI:1245425016
Name:HICKEY, JOHN SCOTT (PH D)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:SCOTT
Last Name:HICKEY
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3418 MERCER ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77027-6527
Mailing Address - Country:US
Mailing Address - Phone:713-961-0651
Mailing Address - Fax:
Practice Address - Street 1:3418 MERCER ST
Practice Address - Street 2:SUITE 100
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77027-6527
Practice Address - Country:US
Practice Address - Phone:713-961-0651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-13
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23165103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8A5896Medicare PIN