Provider Demographics
NPI:1770292385
Name:HICKS, DARRELL LEE (PRSS)
Entity type:Individual
Prefix:
First Name:DARRELL
Middle Name:LEE
Last Name:HICKS
Suffix:
Gender:M
Credentials:PRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2632 GUYAN AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25702-1151
Mailing Address - Country:US
Mailing Address - Phone:304-373-4085
Mailing Address - Fax:
Practice Address - Street 1:1236 5TH AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-2207
Practice Address - Country:US
Practice Address - Phone:681-204-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-22
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21-970175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist