Provider Demographics
NPI:1770045775
Name:HICKS, BRANDIE J
Entity Type:Individual
Prefix:
First Name:BRANDIE
Middle Name:J
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 1:71338 HIGHWAY 21 STE 101
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-7162
Mailing Address - Country:US
Mailing Address - Phone:985-624-2942
Mailing Address - Fax:985-231-1373
Practice Address - Street 1:71338 HIGHWAY 21 STE 101
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-7162
Practice Address - Country:US
Practice Address - Phone:985-624-2942
Practice Address - Fax:985-231-1373
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6576101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional