Provider Demographics
NPI:1205581261
Name:HICKS, SHANTELENA MARIE
Entity type:Individual
Prefix:
First Name:SHANTELENA
Middle Name:MARIE
Last Name:HICKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1378 HAMPTON KNOLL DR BLDG 12
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44313-4890
Mailing Address - Country:US
Mailing Address - Phone:234-303-9833
Mailing Address - Fax:
Practice Address - Street 1:526 S MAIN ST STE 107
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44311-4401
Practice Address - Country:US
Practice Address - Phone:330-368-2400
Practice Address - Fax:330-313-3849
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-18
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty