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General NPI Number Information
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NPI Number | 1760834717
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Entity Type | Organization
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Legal Business Name | GENA HICKS, PHD, LLC
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Dates
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Enumeration Date | 07/01/2016
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Last Update Date | 07/01/2016
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Provider Practice Location Address
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Address Line | 1319 W BASELINE RD STE 101-B
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City | LAFAYETTE
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State | CO
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Zip | 80026-9307
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Country | US
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Telephone | 720-414-1315
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Fax | 720-899-3160
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Provider Business Mailing Address
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Address Line | 1319 W BASELINE RD STE 101-B
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City | LAFAYETTE
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State | CO
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Zip | 80026-9307
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Country | US
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Telephone | 720-414-1315
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Fax | 720-899-3160
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Authorized Official
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Title or Position | PSYCHOLOGIST
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Name | DR. GENA HICKS
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Credential | PHD
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Telephone | 720-414-1315
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 0003773
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License Number State | CO
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