Provider Demographics
NPI:1053860569
Name:HICKS, DIANE CAROL (LICSW)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:CAROL
Last Name:HICKS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 STEADY LN
Mailing Address - Street 2:
Mailing Address - City:ASHFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01330-9724
Mailing Address - Country:US
Mailing Address - Phone:413-345-8974
Mailing Address - Fax:
Practice Address - Street 1:54 HARRIS PL STE 105
Practice Address - Street 2:
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-6709
Practice Address - Country:US
Practice Address - Phone:413-345-8974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-26
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1254891041C0700X
VT089.01346961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical