Healthcare Provider Details

I. General information

NPI: 1760834717
Provider Name (Legal Business Name): GENA HICKS, PHD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2016
Last Update Date: 07/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1319 W BASELINE RD STE 101-B
LAFAYETTE CO
80026-9307
US

IV. Provider business mailing address

1319 W BASELINE RD STE 101-B
LAFAYETTE CO
80026-9307
US

V. Phone/Fax

Practice location:
  • Phone: 720-414-1315
  • Fax: 720-899-3160
Mailing address:
  • Phone: 720-414-1315
  • Fax: 720-899-3160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number0003773
License Number StateCO

VIII. Authorized Official

Name: DR. GENA HICKS
Title or Position: PSYCHOLOGIST
Credential: PHD
Phone: 720-414-1315