1033580881 NPI number — DIA DANAE HICKS LPC CADC

Table of content: DIA DANAE HICKS LPC CADC (NPI 1033580881)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033580881 NPI number — DIA DANAE HICKS LPC CADC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HICKS
Provider First Name:
DIA
Provider Middle Name:
DANAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC CADC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033580881
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9378 OLIVE BLVD
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
OLIVETTE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63132-3223
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-730-0083
Provider Business Mailing Address Fax Number:
612-241-2552

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9378 OLIVE BLVD
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
OLIVETTE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63132-3223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-730-0083
Provider Business Practice Location Address Fax Number:
612-241-2552
Provider Enumeration Date:
10/19/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  6614 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: 2014008242 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)