Provider Demographics
NPI:1093790776
Name:HICKS, MITCHELL WAYNE (PHD, ABPP)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:WAYNE
Last Name:HICKS
Suffix:
Gender:M
Credentials:PHD, ABPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3411 N KENNICOTT AVE STE C
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60004-7813
Mailing Address - Country:US
Mailing Address - Phone:630-849-8275
Mailing Address - Fax:224-345-2118
Practice Address - Street 1:3411 N KENNICOTT AVE STE C
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60004-7813
Practice Address - Country:US
Practice Address - Phone:630-849-8275
Practice Address - Fax:224-345-2118
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-005185101YP2500X
IL071-006835103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2925Medicare PIN