Provider Demographics
NPI:1558613406
Name:HICKS, TAMARA
Entity Type:Individual
Prefix:
First Name:TAMARA
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 1:16948 COMMONS CREEK DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-2077
Mailing Address - Country:US
Mailing Address - Phone:980-949-8811
Mailing Address - Fax:980-406-3878
Practice Address - Street 1:4822 ALBEMARLE RD STE 205
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-6668
Practice Address - Country:US
Practice Address - Phone:980-949-8811
Practice Address - Fax:980-406-3878
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-02
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12067101Y00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A12067OtherLPCA