Provider Demographics
NPI:1619613007
Name:HICKS, MACKENZIE (RBT)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:HICKS
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:539 FANNY ANN WAY
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:FL
Mailing Address - Zip Code:32439-7613
Mailing Address - Country:US
Mailing Address - Phone:850-865-7297
Mailing Address - Fax:888-545-1603
Practice Address - Street 1:1846 US HIGHWAY 90 W STE B
Practice Address - Street 2:
Practice Address - City:DEFUNIAK SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32433-1408
Practice Address - Country:US
Practice Address - Phone:850-951-0031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-09
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-23-14794106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst