Provider Demographics
NPI:1518031384
Name:HICKS, LISA (SPEECH LANGUAGE PATH)
Entity Type:Individual
Prefix:MR
First Name:LISA
Middle Name:
Last Name:HICKS
Suffix:
Gender:F
Credentials:SPEECH LANGUAGE PATH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 DUNBAR AVENUE
Mailing Address - Street 2:
Mailing Address - City:DUNBAR
Mailing Address - State:WV
Mailing Address - Zip Code:25064
Mailing Address - Country:US
Mailing Address - Phone:304-768-3307
Mailing Address - Fax:304-768-3620
Practice Address - Street 1:1313 DUNBAR AVENUE
Practice Address - Street 2:
Practice Address - City:DUNBAR
Practice Address - State:WV
Practice Address - Zip Code:25064
Practice Address - Country:US
Practice Address - Phone:304-768-3307
Practice Address - Fax:304-768-3620
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP0994235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0206427000Medicaid