Provider Demographics
NPI:1437160793
Name:HICKMAN, SUZANNE (SLP)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:HICKMAN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1652 FERTIGS RD
Mailing Address - Street 2:
Mailing Address - City:VENUS
Mailing Address - State:PA
Mailing Address - Zip Code:16364
Mailing Address - Country:US
Mailing Address - Phone:814-354-2305
Mailing Address - Fax:
Practice Address - Street 1:224 S MAIN ST
Practice Address - Street 2:SUITE 210
Practice Address - City:SENECA
Practice Address - State:PA
Practice Address - Zip Code:16346
Practice Address - Country:US
Practice Address - Phone:814-677-1390
Practice Address - Fax:814-677-1393
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL004076L235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAHI1853555OtherBLUE SHIELD
PA0018718240003Medicaid