=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417541285
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTINA HICKS THD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2021
-----------------------------------------------------
Last Update Date | 02/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 COUNTRY CLUB DR
-----------------------------------------------------
City | STOCKBRIDGE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30281-7350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-782-7272
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 120 COLONY PARK LN
-----------------------------------------------------
City | LOCUST GROVE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30248-3740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-499-8099
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFT001800
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------