Provider Demographics
NPI:1780089854
Name:HICKS, KIMBERLY (MA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:HICKS
Suffix:
Gender:
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 DRAGONFLY DR
Mailing Address - Street 2:
Mailing Address - City:HOLDEN
Mailing Address - State:ME
Mailing Address - Zip Code:04429-7558
Mailing Address - Country:US
Mailing Address - Phone:970-658-9716
Mailing Address - Fax:
Practice Address - Street 1:31 DRAGONFLY DR
Practice Address - Street 2:
Practice Address - City:HOLDEN
Practice Address - State:ME
Practice Address - Zip Code:04429-7558
Practice Address - Country:US
Practice Address - Phone:970-658-9716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-30
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0013314101YP2500X
101YA0400X, 101YP2500X
MECC7790101YP2500X
SC10007101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)