Healthcare Provider Details

I. General information

NPI: 1518701721
Provider Name (Legal Business Name): KIRSTINA LILLIETH HICKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2024
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 BIRMINGHAM DR STE 240A
CARDIFF CA
92007-1757
US

IV. Provider business mailing address

1143 E SEQUOIA AVE
TULARE CA
93274-4507
US

V. Phone/Fax

Practice location:
  • Phone: 858-208-0121
  • Fax:
Mailing address:
  • Phone: 559-579-4270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number20556
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: