Provider Demographics
NPI:1013463850
Name:HICKS, MISTY (MS)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:HICKS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 112
Mailing Address - Street 2:
Mailing Address - City:PONCE DE LEON
Mailing Address - State:FL
Mailing Address - Zip Code:32455-0112
Mailing Address - Country:US
Mailing Address - Phone:850-307-2828
Mailing Address - Fax:
Practice Address - Street 1:1427 HWY 90
Practice Address - Street 2:
Practice Address - City:PONCE DE LEON
Practice Address - State:FL
Practice Address - Zip Code:32455-0112
Practice Address - Country:US
Practice Address - Phone:850-307-2828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0-16-7217103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst