Provider Demographics
NPI:1396400297
Name:HICKS, CAMILLIA ANNETT
Entity Type:Individual
Prefix:
First Name:CAMILLIA
Middle Name:ANNETT
Last Name:HICKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2106 BLACKBERRY CRK
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48519-1933
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2700 ROBERT T LONGWAY BLVD STE C
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-2190
Practice Address - Country:US
Practice Address - Phone:810-496-4955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-04
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician