Provider Demographics
NPI:1639412950
Name:HICKOK, SHELLIE IRENE
Entity Type:Individual
Prefix:MRS
First Name:SHELLIE
Middle Name:IRENE
Last Name:HICKOK
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 1:6074 DONCASTER DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-3234
Mailing Address - Country:US
Mailing Address - Phone:907-274-0060
Mailing Address - Fax:
Practice Address - Street 1:6074 DONCASTER DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-3234
Practice Address - Country:US
Practice Address - Phone:907-274-0060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-04
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities