Healthcare Provider Details

I. General information

NPI: 1942429691
Provider Name (Legal Business Name): STEPHANIE MARIE HICKS D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

654 BROADMOOR DR
CHESTERFIELD MO
63017-3163
US

IV. Provider business mailing address

3394 MCKELVEY RD SUITE 114
BRIDGETON MO
63044-2531
US

V. Phone/Fax

Practice location:
  • Phone: 314-374-9399
  • Fax:
Mailing address:
  • Phone: 314-374-9399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2007007207
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: