Provider Demographics
NPI:1356320212
Name:HICKS, WALLACE KENT (EDD)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:KENT
Last Name:HICKS
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7400 NEW LA GRANGE RD
Mailing Address - Street 2:STE 312
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-4870
Mailing Address - Country:US
Mailing Address - Phone:502-394-9990
Mailing Address - Fax:502-394-9992
Practice Address - Street 1:7400 NEW LA GRANGE RD
Practice Address - Street 2:STE 312
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-4870
Practice Address - Country:US
Practice Address - Phone:502-394-9990
Practice Address - Fax:502-394-9992
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY 0227103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY009407OtherVALUE OPTIONS
KY179497OtherCOMPSYCH
KY4139574OtherAETNA
KY4716671OtherCIGNA HEALTHCARE
KY89002273Medicaid
KY130222OtherAPS
KY461331000OtherMAGELLAN
KY1058075OtherCIGNA BEHAVIORAL HEALTH
KY6162200OtherUNITED BEHAVIORAL HEALTH
KY93040OtherMHN
KY000000342982OtherANTHEM
KY4139574OtherAETNA
KYR81664Medicare UPIN