1770049959 NPI number — AZITA HICKEY PH D PSYCHOLOGIST

Table of content: (NPI 1770049959)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770049959 NPI number — AZITA HICKEY PH D PSYCHOLOGIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AZITA HICKEY PH D PSYCHOLOGIST
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770049959
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9921 CARMEL MOUNTAIN RD STE 204
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92129-2813
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-880-9008
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2831 CAMINO DEL RIO S STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92108-3827
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-880-9008
Provider Business Practice Location Address Fax Number:
909-660-4997
Provider Enumeration Date:
02/13/2019

Additional Information

Authorized Official

Authorized Official Last Name:
HICKEY
Authorized Official First Name:
AZITA
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICER/PRESIDENT
Authorized Official Telephone Number:
909-957-0556

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PSY30683 . This is a "LICENSE, CLINICAL PSYCHOLOGIST" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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