Provider Demographics
NPI:1982883211
Name:HICKS, SUSAN ANN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ANN
Last Name:HICKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:ANN
Other - Last Name:BLISS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:35 HAMBRICK RD
Mailing Address - Street 2:
Mailing Address - City:NITRO
Mailing Address - State:WV
Mailing Address - Zip Code:25143-1172
Mailing Address - Country:US
Mailing Address - Phone:304-776-1248
Mailing Address - Fax:
Practice Address - Street 1:16 LEON SULLIVAN WAY
Practice Address - Street 2:SUITE 300
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-2402
Practice Address - Country:US
Practice Address - Phone:304-346-9689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-02
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP0094265D1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0653301Medicare PIN