Provider Demographics
NPI:1417541285
Name:HICKS, CHRISTINA (THD)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:HICKS
Suffix:
Gender:F
Credentials:THD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 COLONY PARK LN
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:GA
Mailing Address - Zip Code:30248-3740
Mailing Address - Country:US
Mailing Address - Phone:678-499-8099
Mailing Address - Fax:
Practice Address - Street 1:301 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7350
Practice Address - Country:US
Practice Address - Phone:678-782-7272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT001800106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist