Provider Demographics
NPI:1184384174
Name:HICKS, SAMUEL THEODORE II
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:THEODORE
Last Name:HICKS
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 ALKEN AVE
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11783-1404
Mailing Address - Country:US
Mailing Address - Phone:631-339-4617
Mailing Address - Fax:
Practice Address - Street 1:1315 ALKEN AVE
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:NY
Practice Address - Zip Code:11783-1404
Practice Address - Country:US
Practice Address - Phone:631-339-4617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-18
Last Update Date:2021-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant