Provider Demographics
NPI:1043561665
Name:HICKSON, TINA MARIE (LMT)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:HICKSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9080 MOONSHINE HOLW APT A
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20723-1638
Mailing Address - Country:US
Mailing Address - Phone:240-459-3044
Mailing Address - Fax:
Practice Address - Street 1:5525 TWIN KNOLLS RD
Practice Address - Street 2:SUITE 321
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-3266
Practice Address - Country:US
Practice Address - Phone:240-459-3044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-21
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM04294225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist