Healthcare Provider Details

I. General information

NPI: 1801384748
Provider Name (Legal Business Name): KELSEY HICKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2018
Last Update Date: 04/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 CANAL ST STE 404
POOLER GA
31322-4088
US

IV. Provider business mailing address

2580 LIN DO CT
SUMTER SC
29150-1832
US

V. Phone/Fax

Practice location:
  • Phone: 912-988-1444
  • Fax:
Mailing address:
  • Phone: 803-905-4427
  • Fax: 803-905-4427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number17-43494
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: