Healthcare Provider Details

I. General information

NPI: 1164932596
Provider Name (Legal Business Name): IVORIE HICKS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2017
Last Update Date: 04/21/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 FORBES BLVD STE B
LANHAM MD
20706-4446
US

IV. Provider business mailing address

4301 FORBES BLVD STE B
LANHAM MD
20706-4446
US

V. Phone/Fax

Practice location:
  • Phone: 240-487-6946
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: