Provider Demographics
NPI:1972073674
Name:HICKS, LAUREN ACOSTA (OTR/L)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:ACOSTA
Last Name:HICKS
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26821 LA ALAMEDA APT 223
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-7328
Mailing Address - Country:US
Mailing Address - Phone:949-584-4017
Mailing Address - Fax:
Practice Address - Street 1:970 CALLE AMANECER STE A
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-6250
Practice Address - Country:US
Practice Address - Phone:949-498-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19301225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics