Provider Demographics
NPI:1457649014
Name:HICKEY, TINA MARIE
Entity Type:Individual
Prefix:MISS
First Name:TINA
Middle Name:MARIE
Last Name:HICKEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:647 S PRAIRIE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-2870
Mailing Address - Country:US
Mailing Address - Phone:217-245-5095
Mailing Address - Fax:217-245-5095
Practice Address - Street 1:647 S PRAIRIE ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-2870
Practice Address - Country:US
Practice Address - Phone:217-245-5095
Practice Address - Fax:217-245-5095
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-18
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency