Provider Demographics
NPI:1649098054
Name:MICKEY, ALIYAH VICIA
Entity type:Individual
Prefix:
First Name:ALIYAH
Middle Name:VICIA
Last Name:MICKEY
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 1:2625 N MERIDIAN ST APT 924
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46208-7709
Mailing Address - Country:US
Mailing Address - Phone:304-237-8068
Mailing Address - Fax:
Practice Address - Street 1:120 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46204-1312
Practice Address - Country:US
Practice Address - Phone:317-226-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10229462103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool