Provider Demographics
NPI:1386040830
Name:HICKS, KERIANNE MARIE (MA, LBS)
Entity Type:Individual
Prefix:MRS
First Name:KERIANNE
Middle Name:MARIE
Last Name:HICKS
Suffix:
Gender:F
Credentials:MA, LBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:837 GARIBALDI AVE
Mailing Address - Street 2:
Mailing Address - City:ROSETO
Mailing Address - State:PA
Mailing Address - Zip Code:18013-1001
Mailing Address - Country:US
Mailing Address - Phone:570-656-8936
Mailing Address - Fax:
Practice Address - Street 1:837 GARIBALDI AVE
Practice Address - Street 2:
Practice Address - City:ROSETO
Practice Address - State:PA
Practice Address - Zip Code:18013-1001
Practice Address - Country:US
Practice Address - Phone:570-656-8936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-11
Last Update Date:2014-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH002480103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst