Provider Demographics
NPI:1275295248
Name:HICKEY, MADISON NICOLE (COTA/L)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:NICOLE
Last Name:HICKEY
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7108 S KANNER HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-7462
Mailing Address - Country:US
Mailing Address - Phone:855-832-6727
Mailing Address - Fax:
Practice Address - Street 1:332 S MICHIGAN AVE STE 900
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60604-4393
Practice Address - Country:US
Practice Address - Phone:217-793-4880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-07
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057005340224Z00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant