Provider Demographics
NPI:1598192296
Name:HICKS, NANNETTE LOUISE (LISAC)
Entity Type:Individual
Prefix:
First Name:NANNETTE
Middle Name:LOUISE
Last Name:HICKS
Suffix:
Gender:F
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8727 W WETHERSFIELD RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-8111
Mailing Address - Country:US
Mailing Address - Phone:602-509-4675
Mailing Address - Fax:602-252-0830
Practice Address - Street 1:8727 W WETHERSFIELD RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-8111
Practice Address - Country:US
Practice Address - Phone:602-509-4675
Practice Address - Fax:602-252-0830
Is Sole Proprietor?:No
Enumeration Date:2013-09-26
Last Update Date:2013-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC11455101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)