Provider Demographics
NPI:1114315140
Name:HICKS, BENJAMIN (MS, ATC)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:HICKS
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 EMERSON RD
Mailing Address - Street 2:SUITE 20
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6739
Mailing Address - Country:US
Mailing Address - Phone:314-325-3068
Mailing Address - Fax:314-325-3069
Practice Address - Street 1:633 EMERSON RD
Practice Address - Street 2:SUITE 20
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-6739
Practice Address - Country:US
Practice Address - Phone:314-325-3068
Practice Address - Fax:314-325-3069
Is Sole Proprietor?:No
Enumeration Date:2014-12-29
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20140288502255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer