Provider Demographics
NPI:1316691942
Name:HICKEY, MICHAEL BRUCE (PMH-BC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BRUCE
Last Name:HICKEY
Suffix:
Gender:M
Credentials:PMH-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 ALLEN ST APT 3D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10002-5332
Mailing Address - Country:US
Mailing Address - Phone:646-330-9198
Mailing Address - Fax:
Practice Address - Street 1:88 LEONARD ST APT 907
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-3498
Practice Address - Country:US
Practice Address - Phone:646-330-9198
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-11
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY680651163WP0808X
NY404786363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health