Basic Information
| Provider Information | |||||||||
| NPI: | 1699083667 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HICKEY COVINGTON | ||||||||
| FirstName: | GENEVIEVE | ||||||||
| MiddleName: | |||||||||
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| Credential: | BCBA | ||||||||
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| OtherLastName: | HICKEY | ||||||||
| OtherFirstName: | GENEVIEVE | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 528 PELICAN KEY | ||||||||
| Address2: | |||||||||
| City: | ATLANTIC BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322334300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043336065 | ||||||||
| FaxNumber: | 9046472625 | ||||||||
| Practice Location | |||||||||
| Address1: | 9141 CYPRESS GREEN DR | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322562013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046471849 | ||||||||
| FaxNumber: | 9046472625 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2010 | ||||||||
| LastUpdateDate: | 06/26/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 0114101 | FL | Y | Behavioral Health & Social Service Providers | Behavioral Analyst | 222Q00000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
No ID Information.