Provider Demographics
NPI:1922589738
Name:RICKEY, ALEXANDER THOMAS (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:THOMAS
Last Name:RICKEY
Suffix:
Gender:M
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 1:275 THORNE AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45177-1217
Mailing Address - Country:US
Mailing Address - Phone:937-382-7556
Mailing Address - Fax:
Practice Address - Street 1:769 ROMBACH AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177-1999
Practice Address - Country:US
Practice Address - Phone:937-382-2443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.13609235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0358990Medicaid