Provider Demographics
NPI:1497762611
Name:HICKS, SUSAN M (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:M
Last Name:HICKS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 NORTH LOOP
Mailing Address - Street 2:
Mailing Address - City:RHINEBECK
Mailing Address - State:NY
Mailing Address - Zip Code:12572-1917
Mailing Address - Country:US
Mailing Address - Phone:845-876-5899
Mailing Address - Fax:
Practice Address - Street 1:230 NORTH RD
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-1328
Practice Address - Country:US
Practice Address - Phone:845-486-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0314111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNP2481Medicare ID - Type UnspecifiedMEDICARE PROVIDER