Provider Demographics
NPI:1689767097
Name:HICKLE, POLLY ANN (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:POLLY
Middle Name:ANN
Last Name:HICKLE
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3840 N CALUSA PT
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34428-6210
Mailing Address - Country:US
Mailing Address - Phone:352-795-8651
Mailing Address - Fax:
Practice Address - Street 1:3840 N CALUSA PT
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34428-6210
Practice Address - Country:US
Practice Address - Phone:352-795-8651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 70235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist