Healthcare Provider Details

I. General information

NPI: 1417360355
Provider Name (Legal Business Name): TIMOTHY RYAN HICKS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2014
Last Update Date: 04/22/2020
Certification Date: 04/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12050 N. PECOS ST. STE 170
WESTMINSTER CO
80234-2015
US

IV. Provider business mailing address

12050 N. PECOS ST. STE 170
WESTMINSTER CO
80234-2015
US

V. Phone/Fax

Practice location:
  • Phone: 720-648-8285
  • Fax: 720-808-1594
Mailing address:
  • Phone: 720-648-8285
  • Fax: 720-808-1594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC0014901
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: