Provider Demographics
NPI:1629735758
Name:HICKS, MICHELLE MCCLAREN
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MCCLAREN
Last Name:HICKS
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 1:900 N SUMNER AVE
Mailing Address - Street 2:
Mailing Address - City:CRESTON
Mailing Address - State:IA
Mailing Address - Zip Code:50801-1351
Mailing Address - Country:US
Mailing Address - Phone:641-247-9455
Mailing Address - Fax:
Practice Address - Street 1:221 W ADAMS ST
Practice Address - Street 2:
Practice Address - City:CRESTON
Practice Address - State:IA
Practice Address - Zip Code:50801-3106
Practice Address - Country:US
Practice Address - Phone:641-782-6620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-23
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA095964235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist