Provider Demographics
NPI:1407548621
Name:HICKS, VICTORIA MARIE
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:MARIE
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 1:2480 WINDY HILL RD SE STE 210
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-8644
Mailing Address - Country:US
Mailing Address - Phone:770-609-7924
Mailing Address - Fax:
Practice Address - Street 1:2480 WINDY HILL RD SE STE 210
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8644
Practice Address - Country:US
Practice Address - Phone:770-609-7924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-25
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC011486101YM0800X
GAMFT001881106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health