Provider Demographics
NPI:1275589269
Name:HICKS, THOMAS V (PHD, LP)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:V
Last Name:HICKS
Suffix:
Gender:M
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 AMERICAN BLVD E
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55420-1392
Mailing Address - Country:US
Mailing Address - Phone:952-854-2622
Mailing Address - Fax:952-854-3293
Practice Address - Street 1:900 AMERICAN BLVD E
Practice Address - Street 2:SUITE 201
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420-1392
Practice Address - Country:US
Practice Address - Phone:952-854-2622
Practice Address - Fax:952-854-3293
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 4530103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN112341OtherHEALTHPARTNERS PROVIDER #
MN61-94690OtherMEDICA PROVIDER NUMBER
MN057G8HIOtherBC/BS PROVIDER NUMBER