MEDICARE: TAMARA HICKS MS, LCMHC

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	101Y00000X	Counselor	12067	NC
2	101YM0800X	Mental Health Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	A12067	OTHER		LPCA

General Provider Information

NPI Number	:	1558613406
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMARA HICKS MS, LCMHC

Provider Business Mailing Address
First Line	:	16948 COMMONS CREEK DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28277-2077
Country	:	US
Telephone Number	:	980-949-8811
Fax Number	:	980-406-3878

Provider Business Practice Location Address
First Line	:	5501 EXECUTIVE CENTER DR STE 217
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28212-8823
Country	:	US
Telephone Number	:	980-949-8811
Fax Number	:	980-406-3878

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

Provider Enumeration Date	:	10/02/2012
Last Update Date	:	11/05/2024

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