Provider Demographics
NPI:1710767652
Name:HICKS, MIRANDA PAIGE
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:PAIGE
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 1:119 LOYOLA AVE
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-2315
Mailing Address - Country:US
Mailing Address - Phone:623-208-3318
Mailing Address - Fax:
Practice Address - Street 1:119 LOYOLA AVE
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-2315
Practice Address - Country:US
Practice Address - Phone:623-208-3318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-28
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician