Healthcare Provider Details

I. General information

NPI: 1144658089
Provider Name (Legal Business Name): RANDY FICKLIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2013
Last Update Date: 10/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 HEMPSTEAD AVE STE H9
ROCKVILLE CENTRE NY
11570-4034
US

IV. Provider business mailing address

30 HEMPSTEAD AVE STE H9
ROCKVILLE CENTRE NY
11570-4034
US

V. Phone/Fax

Practice location:
  • Phone: 516-764-5522
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: