Provider Demographics
NPI:1710069984
Name:HICKS, MARTHA (SP)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:HICKS
Suffix:
Gender:F
Credentials:SP
Other - Prefix:
Other - First Name:MARCY
Other - Middle Name:
Other - Last Name:HICKS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:SP
Mailing Address - Street 1:1176 RIDDLEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:HIGHLANDS RANCH
Mailing Address - State:CO
Mailing Address - Zip Code:80129-6990
Mailing Address - Country:US
Mailing Address - Phone:303-949-4434
Mailing Address - Fax:
Practice Address - Street 1:1176 RIDDLEWOOD LN
Practice Address - Street 2:
Practice Address - City:HIGHLANDS RANCH
Practice Address - State:CO
Practice Address - Zip Code:80129-6990
Practice Address - Country:US
Practice Address - Phone:303-949-4434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO12055782208100000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCPROtherDESERT MTN AFFLIATE