Healthcare Provider Details

I. General information

NPI: 1114049624
Provider Name (Legal Business Name): MARLA KAREL HICKS LM, CPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 01/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4135 54TH PL
SAN DIEGO CA
92105-2303
US

IV. Provider business mailing address

8030 LA MESA BLVD # 143
LA MESA CA
91941-6435
US

V. Phone/Fax

Practice location:
  • Phone: 619-825-5590
  • Fax: 619-741-7053
Mailing address:
  • Phone: 619-825-5590
  • Fax: 619-741-7053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number292568
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code175L00000X
TaxonomyHomeopath
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberLM 155
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: