Provider Demographics
NPI:1740848233
Name:HICKS, VICTORIA VICTOROVNA
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:VICTOROVNA
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 1:9850 19TH ST APT 95
Mailing Address - Street 2:
Mailing Address - City:ALTA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91737-4220
Mailing Address - Country:US
Mailing Address - Phone:909-919-4598
Mailing Address - Fax:
Practice Address - Street 1:9850 19TH ST APT 95
Practice Address - Street 2:
Practice Address - City:ALTA LOMA
Practice Address - State:CA
Practice Address - Zip Code:91737-4220
Practice Address - Country:US
Practice Address - Phone:909-919-4598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-30
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty