1760834717 NPI number — GENA HICKS, PHD, LLC

Table of content: DR. DENNIS EDWARD MCCUNNIFF MD (NPI 1518955962)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760834717 NPI number — GENA HICKS, PHD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GENA HICKS, PHD, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1760834717
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1319 W BASELINE RD
Provider Second Line Business Mailing Address:
STE 101-B
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80026-9307
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
720-414-1315
Provider Business Mailing Address Fax Number:
720-899-3160

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1319 W BASELINE RD
Provider Second Line Business Practice Location Address:
STE 101-B
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80026-9307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
720-414-1315
Provider Business Practice Location Address Fax Number:
720-899-3160
Provider Enumeration Date:
07/01/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HICKS
Authorized Official First Name:
GENA
Authorized Official Middle Name:
Authorized Official Title or Position:
PSYCHOLOGIST
Authorized Official Telephone Number:
720-414-1315

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  0003773 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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