Provider Demographics
NPI:1104703826
Name:HICKEY, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:HICKEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5125 SAVONA CAMPBELL RD
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:NY
Mailing Address - Zip Code:14821-9788
Mailing Address - Country:US
Mailing Address - Phone:585-363-1660
Mailing Address - Fax:
Practice Address - Street 1:105 E 1ST ST
Practice Address - Street 2:
Practice Address - City:CORNING
Practice Address - State:NY
Practice Address - Zip Code:14830-2710
Practice Address - Country:US
Practice Address - Phone:607-205-8848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-18
Last Update Date:2025-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY087353104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker