Provider Demographics
NPI:1902680713
Name:BLATZHEIM HICKEY, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:BLATZHEIM 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 1:24321 S WILLIAM DR
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:IL
Mailing Address - Zip Code:60442-8464
Mailing Address - Country:US
Mailing Address - Phone:815-931-5985
Mailing Address - Fax:
Practice Address - Street 1:400 E LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-1992
Practice Address - Country:US
Practice Address - Phone:779-707-3717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-22
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker