MEDICARE: DR. SCOTT OWEN HICKMAN PSYD

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	103TC0700X	Clinical Psychologist	33374	TX

General Provider Information

NPI Number	:	1093927667
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SCOTT OWEN HICKMAN PSYD

Provider Business Mailing Address
First Line	:	1664 KELLER PKWY STE 103
Second Line	:
City	:	KELLER
State	:	TX
Zip	:	76248-3760
Country	:	US
Telephone Number	:	817-253-4686
Fax Number	:

Provider Business Practice Location Address
First Line	:	1664 KELLER PKWY STE 103
Second Line	:
City	:	KELLER
State	:	TX
Zip	:	76248-3760
Country	:	US
Telephone Number	:	817-253-4686
Fax Number	:

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

Provider Enumeration Date	:	05/04/2007
Last Update Date	:	07/12/2009

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