Provider Demographics
NPI:1578173241
Name:HICKMAN, KELLEY
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:HICKMAN
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 1:98-1247 KAAHUMANU ST STE 319
Mailing Address - Street 2:
Mailing Address - City:AIEA
Mailing Address - State:HI
Mailing Address - Zip Code:96701-5301
Mailing Address - Country:US
Mailing Address - Phone:808-773-7474
Mailing Address - Fax:
Practice Address - Street 1:897 S 55TH PL
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97478-6978
Practice Address - Country:US
Practice Address - Phone:541-905-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist