Provider Demographics
NPI:1841941499
Name:HICKS, KERRY JAMES (RADT)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:JAMES
Last Name:HICKS
Suffix:
Gender:M
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66275 IRONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:DESERT HOT SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92240-5828
Mailing Address - Country:US
Mailing Address - Phone:916-936-7712
Mailing Address - Fax:
Practice Address - Street 1:44199 MONROE ST STE B
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-3094
Practice Address - Country:US
Practice Address - Phone:760-863-8074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-14
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1404530920106S00000X
CA101YA0400X, 175T00000X
171M00000X
CA17453101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist