MEDICARE: MR. DENNIS R HICKS MFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	MFT27240	CA

General Provider Information

NPI Number	:	1407921661
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DENNIS R HICKS MFT

Provider Business Mailing Address
First Line	:	938 MARCO PL
Second Line	:
City	:	VENICE
State	:	CA
Zip	:	90291-3920
Country	:	US
Telephone Number	:	310-823-9556
Fax Number	:	310-306-2296

Provider Business Practice Location Address
First Line	:	11600 WASHINGTON PL STE 201
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90066-5068
Country	:	US
Telephone Number	:	310-390-8646
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/22/2006
Last Update Date	:	07/08/2007

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