MEDICARE: MS. MARY HASTY HICKOK LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	103962	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1893076	OTHER	MA	BC
2	249652	OTHER	MA	MAGELLAN
3	1893076	OTHER	MA	MBHP

General Provider Information

NPI Number	:	1003958992
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY HASTY HICKOK LICSW

Provider Business Mailing Address
First Line	:	62 SOUTH ST
Second Line	:
City	:	WILLIAMSBURG
State	:	MA
Zip	:	01096-9726
Country	:	US
Telephone Number	:	413-348-8275
Fax Number	:	413-582-6956

Provider Business Practice Location Address
First Line	:	62 SOUTH ST
Second Line	:
City	:	WILLIAMSBURG
State	:	MA
Zip	:	01096-9726
Country	:	US
Telephone Number	:	413-348-8275
Fax Number	:	413-582-6956

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/14/2007
Last Update Date	:	04/29/2022

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