Basic Information
| Provider Information | |||||||||
| NPI: | 1700820479 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FICKLE | ||||||||
| FirstName: | DEBBIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | CO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1012 S STAPLEY DR BLDG 5 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852044270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807686022 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1012 S STAPLEY DR BLDG 5 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852044270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807686022 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 07/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 330034005 | 01 | AL | MEDICAID REHAB | OTHER |