Provider Demographics
NPI:1568974145
Name:HICKS, MICHAELE
Entity Type:Individual
Prefix:
First Name:MICHAELE
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 1:17 PARK VIEW ST
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02121-1608
Mailing Address - Country:US
Mailing Address - Phone:617-682-5692
Mailing Address - Fax:
Practice Address - Street 1:17 PARK VIEW ST
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02121-1608
Practice Address - Country:US
Practice Address - Phone:617-682-5692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-03
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician