Provider Demographics
NPI:1770049959
Name:AZITA HICKEY PH D PSYCHOLOGIST
Entity type:Organization
Organization Name:AZITA HICKEY PH D PSYCHOLOGIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AZITA
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:909-957-0556
Mailing Address - Street 1:9921 CARMEL MOUNTAIN RD STE 204
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92129-2813
Mailing Address - Country:US
Mailing Address - Phone:619-880-9008
Mailing Address - Fax:
Practice Address - Street 1:2831 CAMINO DEL RIO S STE 103
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3827
Practice Address - Country:US
Practice Address - Phone:619-880-9008
Practice Address - Fax:909-660-4997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-13
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY30683OtherLICENSE, CLINICAL PSYCHOLOGIST