Healthcare Provider Details

I. General information

NPI: 1841941499
Provider Name (Legal Business Name): KERRY JAMES HICKS SUDCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2022
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44199 MONROE ST STE B
INDIO CA
92201-3094
US

IV. Provider business mailing address

44199 MONROE ST
INDIO CA
92201-3096
US

V. Phone/Fax

Practice location:
  • Phone: 760-863-8074
  • Fax:
Mailing address:
  • Phone: 916-936-7712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number17453
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number17453
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberR1404530920
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: