Healthcare Provider Details

I. General information

NPI: 1508932849
Provider Name (Legal Business Name): GAYLE ELLEN HICKS PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 08/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2815 CAMINO DEL RIO SOUTH SUITE 220
SAN DIEGO CA
92108
US

IV. Provider business mailing address

2815 CAMINO DEL RIO S SUITE 220
SAN DIEGO CA
92108-3815
US

V. Phone/Fax

Practice location:
  • Phone: 858-279-6771
  • Fax: 858-279-7505
Mailing address:
  • Phone: 858-279-6771
  • Fax: 858-279-7505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License NumberAU 511
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAU 511
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberHA 2992
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: