Healthcare Provider Details

I. General information

NPI: 1649920497
Provider Name (Legal Business Name): JAMES LEE HICKS AAS CDAC1
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2022
Last Update Date: 11/28/2024
Certification Date: 11/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1904 RICHLAND AVE
CERES CA
95307-4562
US

IV. Provider business mailing address

102 OLIVE AVE
MODESTO CA
95350-5931
US

V. Phone/Fax

Practice location:
  • Phone: 209-525-7411
  • Fax: 209-541-2083
Mailing address:
  • Phone: 209-735-2633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: