=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629897897
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MISS MACEY LEE HICKS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2024
-----------------------------------------------------
Last Update Date | 10/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 567 WABASH AVE NW
-----------------------------------------------------
City | NEW PHILA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44663-4143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-343-3050
-----------------------------------------------------
Fax | 330-343-3150
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 760 WILLOW DALE ST NW
-----------------------------------------------------
City | BOLIVAR
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44612-9219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-705-1073
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------