Provider Demographics
NPI:1467773903
Name:HICKS, AMY JO
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JO
Last Name:HICKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:JO
Other - Last Name:PARRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:90 HOPE DR
Mailing Address - Street 2:BLDG. 6000
Mailing Address - City:MOUNTAIN HOME A F B
Mailing Address - State:ID
Mailing Address - Zip Code:83648-1057
Mailing Address - Country:US
Mailing Address - Phone:208-828-7580
Mailing Address - Fax:208-828-3940
Practice Address - Street 1:90 HOPE DR
Practice Address - Street 2:BLDG. 6000
Practice Address - City:MOUNTAIN HOME A F B
Practice Address - State:ID
Practice Address - Zip Code:83648-1057
Practice Address - Country:US
Practice Address - Phone:208-828-7580
Practice Address - Fax:208-828-3940
Is Sole Proprietor?:No
Enumeration Date:2010-06-18
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW 273711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical