Provider Demographics
NPI:1417360355
Name:HICKS, TIMOTHY RYAN
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:RYAN
Last Name:HICKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12050 N. PECOS ST.
Mailing Address - Street 2:STE 170
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80234-2015
Mailing Address - Country:US
Mailing Address - Phone:720-648-8285
Mailing Address - Fax:720-808-1594
Practice Address - Street 1:12050 N. PECOS ST.
Practice Address - Street 2:STE 170
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80234-2015
Practice Address - Country:US
Practice Address - Phone:720-648-8285
Practice Address - Fax:720-808-1594
Is Sole Proprietor?:No
Enumeration Date:2014-06-09
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
COLPC0014901101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator