Provider Demographics
NPI:1932202017
Name:HICKA, JOHN EDWARD (MSW LCSW)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:EDWARD
Last Name:HICKA
Suffix:
Gender:M
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 WEST MAIN ST
Mailing Address - Street 2:STE 106C
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902
Mailing Address - Country:US
Mailing Address - Phone:203-323-1847
Mailing Address - Fax:203-698-3443
Practice Address - Street 1:2001 WEST MAIN ST
Practice Address - Street 2:STE 106C
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902
Practice Address - Country:US
Practice Address - Phone:203-323-1847
Practice Address - Fax:203-698-3443
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005068103TP0814X, 103T00000X
NY052839103TP0814X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTP2469164OtherOXFORD