Provider Demographics
NPI:1669858684
Name:HICKS, DEMETRIUS ANTONYO CONTELLIS II
Entity Type:Individual
Prefix:
First Name:DEMETRIUS
Middle Name:ANTONYO CONTELLIS
Last Name:HICKS
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24275 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-7285
Mailing Address - Country:US
Mailing Address - Phone:951-677-5599
Mailing Address - Fax:
Practice Address - Street 1:1461 E COOLEY DR STE 100
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-3921
Practice Address - Country:US
Practice Address - Phone:909-320-0064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-31
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF98596106H00000X, 106H00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist