Provider Demographics
NPI:1649534322
Name:HICKS, BEVERLY W (RN)
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:W
Last Name:HICKS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:378 TABOR RD
Mailing Address - Street 2:
Mailing Address - City:FORT VALLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31030-6024
Mailing Address - Country:US
Mailing Address - Phone:478-971-4684
Mailing Address - Fax:
Practice Address - Street 1:378 TABOR RD
Practice Address - Street 2:
Practice Address - City:FORT VALLEY
Practice Address - State:GA
Practice Address - Zip Code:31030-6024
Practice Address - Country:US
Practice Address - Phone:478-971-4684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-27
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN081233103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst