Provider Demographics
NPI:1881719532
Name:HICKS, KENNETH (MA, LCSW)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:HICKS
Suffix:
Gender:M
Credentials:MA, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9323 SOUTH EMERALD AVENUE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60620
Mailing Address - Country:US
Mailing Address - Phone:773-858-6999
Mailing Address - Fax:
Practice Address - Street 1:308 EAST 21ST AVENUE
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46407
Practice Address - Country:US
Practice Address - Phone:219-886-1320
Practice Address - Fax:219-886-1319
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical