Healthcare Provider Details

I. General information

NPI: 1982394979
Provider Name (Legal Business Name): MARKUS I HICKS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2023
Last Update Date: 05/11/2023
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11712 MOORPARK ST STE 101
STUDIO CITY CA
91604-2155
US

IV. Provider business mailing address

701 S MURIEL DR
BARSTOW CA
92311-3143
US

V. Phone/Fax

Practice location:
  • Phone: 323-839-4880
  • Fax:
Mailing address:
  • Phone: 323-839-4880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number113732
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: