Healthcare Provider Details

I. General information

NPI: 1427472299
Provider Name (Legal Business Name): MIKAL ASHLEY HICKS-BLACK D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2014
Last Update Date: 02/11/2020
Certification Date: 02/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 MONUMENT RD
PHILADELPHIA PA
19131-1625
US

IV. Provider business mailing address

4200 MONUMENT RD
PHILADELPHIA PA
19131-1625
US

V. Phone/Fax

Practice location:
  • Phone: 215-581-3701
  • Fax: 215-581-3993
Mailing address:
  • Phone: 215-977-2000
  • Fax: 215-581-3993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberOT015506
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: