Provider Demographics
NPI:1700097516
Name:HICKS, DEVON M
Entity Type:Individual
Prefix:
First Name:DEVON
Middle Name:M
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 1:423 MACKAY DR
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3230
Mailing Address - Country:US
Mailing Address - Phone:909-383-1073
Mailing Address - Fax:909-383-1456
Practice Address - Street 1:423 MACKAY DR
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3230
Practice Address - Country:US
Practice Address - Phone:909-383-1073
Practice Address - Fax:909-383-1456
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARW0767101YA0400X
CAVN246830164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5155OtherSIMON STAFF NUMBER