Provider Demographics
NPI:1720304496
Name:HICKS, PAMELA WOOD (LCDC)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:WOOD
Last Name:HICKS
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 OLD BULLARD RD STE 402
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-8662
Mailing Address - Country:US
Mailing Address - Phone:903-509-4232
Mailing Address - Fax:903-509-9918
Practice Address - Street 1:3600 OLD BULLARD RD STE 402
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-8662
Practice Address - Country:US
Practice Address - Phone:903-509-4232
Practice Address - Fax:903-509-9918
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-20
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11073101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)