Provider Demographics
NPI:1811168404
Name:HICKEN, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:HICKEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22455 MAPLE CT
Mailing Address - Street 2:SUITE 402
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541-4020
Mailing Address - Country:US
Mailing Address - Phone:510-582-0148
Mailing Address - Fax:510-582-8460
Practice Address - Street 1:22455 MAPLE CT
Practice Address - Street 2:SUITE 402
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94541-4020
Practice Address - Country:US
Practice Address - Phone:501-582-0148
Practice Address - Fax:510-582-8460
Is Sole Proprietor?:No
Enumeration Date:2008-03-21
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23249101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA23249OtherBBS