Provider Demographics
NPI:1013393164
Name:HICKS, ROGER (LMT)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:HICKS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16735 GREENWOOD LN
Mailing Address - Street 2:
Mailing Address - City:WEED
Mailing Address - State:CA
Mailing Address - Zip Code:96094-9451
Mailing Address - Country:US
Mailing Address - Phone:314-974-1014
Mailing Address - Fax:
Practice Address - Street 1:2060 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:YREKA
Practice Address - State:CA
Practice Address - Zip Code:96097-9538
Practice Address - Country:US
Practice Address - Phone:530-598-3554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-30
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator