Provider Demographics
NPI:1356935860
Name:HICKMAN, MIRAKO ZHANAY
Entity type:Individual
Prefix:
First Name:MIRAKO
Middle Name:ZHANAY
Last Name:HICKMAN
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 1:28475 GREENFIELD ROAD
Mailing Address - Street 2:STE 113 #7274
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076
Mailing Address - Country:US
Mailing Address - Phone:313-913-8155
Mailing Address - Fax:
Practice Address - Street 1:28475 GREENFIELD ROAD
Practice Address - Street 2:STE 113 #7274
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076
Practice Address - Country:US
Practice Address - Phone:313-401-6603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-24
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist