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General NPI Number Information
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NPI Number | 1356320212
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Entity Type | Individual
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Provider Name | WALLACE KENT HICKS ED.D.
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Gender | Male
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Dates
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Enumeration Date | 01/10/2006
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Last Update Date | 01/06/2011
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Provider Practice Location Address
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Address Line | 7400 NEW LA GRANGE RD STE 312
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City | LOUISVILLE
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State | KY
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Zip | 40222-4870
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Country | US
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Telephone | 502-394-9990
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Fax | 502-394-9992
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Provider Business Mailing Address
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Address Line | 7400 NEW LA GRANGE RD STE 312
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City | LOUISVILLE
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State | KY
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Zip | 40222-4870
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Country | US
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Telephone | 502-394-9990
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Fax | 502-394-9992
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number | KY 0227
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License Number State | KY
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