Provider Demographics
NPI:1437523594
Name:HICKS, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:HICKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:POWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:501 E SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-9676
Mailing Address - Country:US
Mailing Address - Phone:815-232-0300
Mailing Address - Fax:779-696-5858
Practice Address - Street 1:501 E SOUTH ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-9676
Practice Address - Country:US
Practice Address - Phone:815-232-0300
Practice Address - Fax:779-696-5858
Is Sole Proprietor?:No
Enumeration Date:2015-11-30
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.012946235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist