Provider Demographics
NPI:1700074457
Name:HICKS, INGRID DIANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:INGRID
Middle Name:DIANN
Last Name:HICKS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 N 23RD ST
Mailing Address - Street 2:SUITE #212
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53233-3300
Mailing Address - Country:US
Mailing Address - Phone:414-933-7083
Mailing Address - Fax:414-933-7083
Practice Address - Street 1:835 N 23RD ST
Practice Address - Street 2:SUITE #212
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-3300
Practice Address - Country:US
Practice Address - Phone:414-933-7083
Practice Address - Fax:414-933-7083
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1198103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39038800Medicaid