Provider Demographics
NPI:1841536307
Name:HICKMAN, MICHAEL C (PTA)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:C
Last Name:HICKMAN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 MORGNEC RD.
Mailing Address - Street 2:
Mailing Address - City:CHESTERTWON
Mailing Address - State:MD
Mailing Address - Zip Code:21620
Mailing Address - Country:US
Mailing Address - Phone:410-778-1900
Mailing Address - Fax:
Practice Address - Street 1:415 MORGNEC RD.
Practice Address - Street 2:
Practice Address - City:CHESTERTOWN
Practice Address - State:MD
Practice Address - Zip Code:21620
Practice Address - Country:US
Practice Address - Phone:410-778-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-02
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA2487225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant