Provider Demographics
NPI:1851739296
Name:HICKS, LAURIE ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:ANN
Last Name:HICKS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4971 BONNYVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-4217
Mailing Address - Country:US
Mailing Address - Phone:530-604-3637
Mailing Address - Fax:866-789-4966
Practice Address - Street 1:4971 BONNYVIEW AVE
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-4217
Practice Address - Country:US
Practice Address - Phone:530-604-3637
Practice Address - Fax:866-789-4966
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-07
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACSW89673171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA20280I5251OtherMEDICARE PTAN
GA003134949BMedicaid
GA822720206OtherTAX ID
GA58-1649042OtherTAX ID NUMBER