Provider Demographics
NPI:1356689152
Name:HICKS, BRIAN (MLS)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:
Last Name:HICKS
Suffix:
Gender:M
Credentials:MLS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 WENDELL AVENUE EXT STE 105
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01201-6283
Mailing Address - Country:US
Mailing Address - Phone:413-464-7521
Mailing Address - Fax:877-208-8430
Practice Address - Street 1:10 WENDELL AVENUE EXT STE 105
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-6283
Practice Address - Country:US
Practice Address - Phone:413-464-7521
Practice Address - Fax:877-208-8430
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-29
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
25357723246QM0706X
MA22D2047480291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1497096960OtherNPI