Healthcare Provider Details

I. General information

NPI: 1851556161
Provider Name (Legal Business Name): RODGER HICKS MA, LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2008
Last Update Date: 05/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7550 S STATE ST
LOWVILLE NY
13367-1533
US

IV. Provider business mailing address

PO BOX 91
WATERTOWN NY
13601-0091
US

V. Phone/Fax

Practice location:
  • Phone: 315-376-5450
  • Fax: 315-785-8628
Mailing address:
  • Phone: 315-782-4207
  • Fax: 315-782-8699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number003261
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: