Provider Demographics
NPI:1609450444
Name:HICKS, AUDREY M (RADT)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:M
Last Name:HICKS
Suffix:
Gender:F
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 SIERRA COLLEGE DR (LRC)
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945
Mailing Address - Country:US
Mailing Address - Phone:530-273-9541
Mailing Address - Fax:
Practice Address - Street 1:145 BOST AVE
Practice Address - Street 2:
Practice Address - City:NEVADA CITY
Practice Address - State:CA
Practice Address - Zip Code:95959-3249
Practice Address - Country:US
Practice Address - Phone:530-273-9541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-07
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1424080421101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)