Provider Demographics
NPI:1770219719
Name:HICKS, BERNARD A
Entity Type:Individual
Prefix:MR
First Name:BERNARD
Middle Name:A
Last Name:HICKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4376 163RD ST APT 1A
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358-3201
Mailing Address - Country:US
Mailing Address - Phone:718-666-8361
Mailing Address - Fax:
Practice Address - Street 1:4376 163RD ST APT 1A
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11358-3201
Practice Address - Country:US
Practice Address - Phone:718-666-8361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-30
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1210687499171400000X, 174H00000X, 2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No171400000XOther Service ProvidersHealth & Wellness Coach
No174H00000XOther Service ProvidersHealth Educator