Provider Demographics
NPI:1538230495
Name:HICKMAN, JOHN VICENT (LCSW, CASAC)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:VICENT
Last Name:HICKMAN
Suffix:
Gender:M
Credentials:LCSW, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 BEECH ST
Mailing Address - Street 2:
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-3141
Mailing Address - Country:US
Mailing Address - Phone:631-981-2843
Mailing Address - Fax:
Practice Address - Street 1:15 HORSEBLOCK PL
Practice Address - Street 2:
Practice Address - City:FARMINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:11738-1204
Practice Address - Country:US
Practice Address - Phone:631-854-2571
Practice Address - Fax:631-854-2550
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0459781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00354807Medicaid
NYW02771Medicare ID - Type Unspecified
NY1700989050Medicare UPIN