Provider Demographics
NPI:1225269202
Name:HICKS, CRYSTAL R (PHD)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:R
Last Name:HICKS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MISS
Other - First Name:CRYSTAL
Other - Middle Name:R
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:9349 NOTRE DAME DR APT C
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-4169
Mailing Address - Country:US
Mailing Address - Phone:765-529-3370
Mailing Address - Fax:765-529-7269
Practice Address - Street 1:321 S MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:IN
Practice Address - Zip Code:47362-4218
Practice Address - Country:US
Practice Address - Phone:765-529-3370
Practice Address - Fax:765-529-7269
Is Sole Proprietor?:No
Enumeration Date:2009-08-07
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200077810AMedicaid