Healthcare Provider Details

I. General information

NPI: 1770045775
Provider Name (Legal Business Name): BRANDIE J HICKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2019
Last Update Date: 04/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71338 HIGHWAY 21 STE 101
COVINGTON LA
70433-7162
US

IV. Provider business mailing address

71338 HIGHWAY 21 STE 101
COVINGTON LA
70433-7162
US

V. Phone/Fax

Practice location:
  • Phone: 985-624-2942
  • Fax: 985-231-1373
Mailing address:
  • Phone: 985-624-2942
  • Fax: 985-231-1373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6576
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: