Provider Demographics
NPI:1760834717
Name:GENA HICKS, PHD, LLC
Entity Type:Organization
Organization Name:GENA HICKS, PHD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GENA
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:720-414-1315
Mailing Address - Street 1:1319 W BASELINE RD
Mailing Address - Street 2:STE 101-B
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-9307
Mailing Address - Country:US
Mailing Address - Phone:720-414-1315
Mailing Address - Fax:720-899-3160
Practice Address - Street 1:1319 W BASELINE RD
Practice Address - Street 2:STE 101-B
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-9307
Practice Address - Country:US
Practice Address - Phone:720-414-1315
Practice Address - Fax:720-899-3160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-01
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0003773103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
286248YRZBMedicare PIN