=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912566308
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THERESA EMMA HICKS LAC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2019
-----------------------------------------------------
Last Update Date | 06/10/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 561 TILTON RD
-----------------------------------------------------
City | NORTHFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08225-1217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-667-7819
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 377 DENNISVILLE RD
-----------------------------------------------------
City | CAPE MAY COURT HOUSE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08210-1071
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-201-1346
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 37AC00461700
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------