Provider Demographics
NPI:1982009767
Name:HICKS, COREY (M ED CCC-SLP)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:HICKS
Suffix:
Gender:M
Credentials:M ED CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:653 MONUMENT ROAD APT 1102
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225
Mailing Address - Country:US
Mailing Address - Phone:229-798-3848
Mailing Address - Fax:
Practice Address - Street 1:11512 LAKE MEAD AVENUE SUITE 604
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256
Practice Address - Country:US
Practice Address - Phone:904-652-5408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-23
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 12067235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist