Provider Demographics
NPI:1790310068
Name:HICKS, VIRGINIA ANNE (LMBT)
Entity Type:Individual
Prefix:MS
First Name:VIRGINIA
Middle Name:ANNE
Last Name:HICKS
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16501 NORTHCROSS DR STE D
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-5040
Mailing Address - Country:US
Mailing Address - Phone:980-505-3755
Mailing Address - Fax:
Practice Address - Street 1:16501 NORTHCROSS DR STE D
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-5040
Practice Address - Country:US
Practice Address - Phone:980-505-3755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-07
Last Update Date:2020-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2422-146225700000X
NC16615225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist