Provider Demographics
NPI:1689271926
Name:HICKS, ROSALYN
Entity Type:Individual
Prefix:
First Name:ROSALYN
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:PO BOX 263
Mailing Address - Street 2:
Mailing Address - City:SALLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29137-0263
Mailing Address - Country:US
Mailing Address - Phone:803-800-2899
Mailing Address - Fax:
Practice Address - Street 1:205 POPLAR ST SE
Practice Address - Street 2:
Practice Address - City:SALLEY
Practice Address - State:SC
Practice Address - Zip Code:29137-8949
Practice Address - Country:US
Practice Address - Phone:803-800-2899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator