Provider Demographics
NPI:1467137455
Name:HICKSON, DE ANNA NAKIA
Entity Type:Individual
Prefix:
First Name:DE ANNA
Middle Name:NAKIA
Last Name:HICKSON
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 1:325 W SECOND ST APT A
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-2301
Mailing Address - Country:US
Mailing Address - Phone:610-883-7635
Mailing Address - Fax:
Practice Address - Street 1:110 CHURCH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19106-2201
Practice Address - Country:US
Practice Address - Phone:863-370-6344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician