Provider Demographics
NPI:1831280619
Name:HICKS, TIMOTHY MICHAEL (PCC)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:MICHAEL
Last Name:HICKS
Suffix:
Gender:M
Credentials:PCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 C CT
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-4577
Mailing Address - Country:US
Mailing Address - Phone:440-998-4210
Mailing Address - Fax:
Practice Address - Street 1:2801 C CT
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-4577
Practice Address - Country:US
Practice Address - Phone:440-998-4210
Practice Address - Fax:440-998-6775
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.0008268101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional