Basic Information
Provider Information
NPI: 1003014549
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: HICKS
FirstName: KRISTIN
MiddleName: LYNN
NamePrefix: DR.
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 150 DAVIE BLVD
Address2: SUITE 201
City: FORT LAUDERDALE
State: FL
PostalCode: 33316
CountryCode: US
TelephoneNumber: 9542815080
FaxNumber: 9542067701
Practice Location
Address1: 150 DAVIE BLVD
Address2: SUITE 201
City: FORT LAUDERDALE
State: FL
PostalCode: 33316
CountryCode: US
TelephoneNumber: 9542815080
FaxNumber: 9542067701
Other Information
ProviderEnumerationDate: 07/06/2007
LastUpdateDate: 11/01/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
2084P0800XME113937FLY Allopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry

No ID Information.


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