Provider Demographics
NPI:1437499746
Name:HICKS, MONIQUE
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
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 1:4719 QUAIL LAKES DR STE G471
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-8140
Mailing Address - Country:US
Mailing Address - Phone:209-425-1361
Mailing Address - Fax:
Practice Address - Street 1:834 POLAR BEAR CIR
Practice Address - Street 2:
Practice Address - City:GALT
Practice Address - State:CA
Practice Address - Zip Code:95632-3074
Practice Address - Country:US
Practice Address - Phone:209-425-1361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-22
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CA104839106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist