Provider Demographics
NPI:1255903167
Name:HICKS, MAYA ELAINE (MS,LAT,ATC)
Entity type:Individual
Prefix:MRS
First Name:MAYA
Middle Name:ELAINE
Last Name:HICKS
Suffix:
Gender:F
Credentials:MS,LAT,ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6308 DRY FORK LN
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27617-7615
Mailing Address - Country:US
Mailing Address - Phone:919-417-6832
Mailing Address - Fax:
Practice Address - Street 1:11221 GALLERIA AVE STE 101
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-8137
Practice Address - Country:US
Practice Address - Phone:919-645-9410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-12
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLAT-57072255A2300X
2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty