=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124619978
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUE HICKS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2021
-----------------------------------------------------
Last Update Date | 02/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4477 W EMERALD ST STE C275
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83706-2078
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-740-0391
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5524 S CAPER PL
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83716-6929
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-740-0391
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SUE M HICKS
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 208-740-0391
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------