Healthcare Provider Details

I. General information

NPI: 1003958992
Provider Name (Legal Business Name): MARY HASTY HICKOK LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. HASTY HICKOK

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 04/29/2022
Certification Date: 04/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62 SOUTH ST
WILLIAMSBURG MA
01096-9726
US

IV. Provider business mailing address

62 SOUTH ST
WILLIAMSBURG MA
01096-9726
US

V. Phone/Fax

Practice location:
  • Phone: 413-348-8275
  • Fax: 413-582-6956
Mailing address:
  • Phone: 413-348-8275
  • Fax: 413-582-6956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number103962
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: