Provider Demographics
NPI:1649339524
Name:HICKEY, JAMES MICHAEL
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:MICHAEL
Last Name:HICKEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 HENSHAW ST
Mailing Address - Street 2:SUITE #3
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-2905
Mailing Address - Country:US
Mailing Address - Phone:617-787-4349
Mailing Address - Fax:617-202-4212
Practice Address - Street 1:17 HENSHAW ST
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-2905
Practice Address - Country:US
Practice Address - Phone:617-787-4349
Practice Address - Fax:617-202-4212
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7216103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW50779Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID