Provider Demographics
NPI:1730677386
Name:HICKS, IXCHELLE QUEELEY
Entity Type:Individual
Prefix:
First Name:IXCHELLE
Middle Name:QUEELEY
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 1:1700 COUNTRY TERRACE LN
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32703-5050
Mailing Address - Country:US
Mailing Address - Phone:407-810-4457
Mailing Address - Fax:
Practice Address - Street 1:1002 N SEMORAN BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32807-3531
Practice Address - Country:US
Practice Address - Phone:407-275-8939
Practice Address - Fax:407-282-3674
Is Sole Proprietor?:No
Enumeration Date:2018-04-30
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)