=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043561665
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TINA MARIE HICKSON LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2012
-----------------------------------------------------
Last Update Date | 09/21/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5525 TWIN KNOLLS RD SUITE 321
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21045-3266
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-459-3044
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9080 MOONSHINE HOLW APT A
-----------------------------------------------------
City | LAUREL
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20723-1638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-459-3044
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | M04294
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------