Basic Information
| Provider Information | |||||||||
| NPI: | 1215219076 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HICKS | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | G | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20402 N 15TH AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850273636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6234454952 | ||||||||
| FaxNumber: | 6234455095 | ||||||||
| Practice Location | |||||||||
| Address1: | 20402 N 15TH AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850273636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6234454952 | ||||||||
| FaxNumber: | 6234455095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2011 | ||||||||
| LastUpdateDate: | 09/16/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TS0200X | 3537888 | AZ | Y | Behavioral Health & Social Service Providers | Psychologist | School |
No ID Information.