Provider Demographics
NPI:1750584314
Name:HICKEY, IDALIA BERENICE (BA)
Entity type:Individual
Prefix:
First Name:IDALIA
Middle Name:BERENICE
Last Name:HICKEY
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 N VIA ENTRADA APT 2057
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718-5873
Mailing Address - Country:US
Mailing Address - Phone:520-405-1710
Mailing Address - Fax:
Practice Address - Street 1:4601 N VIA ENTRADA APT 2057
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718-5873
Practice Address - Country:US
Practice Address - Phone:520-405-1710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPL5459235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist