MEDICARE: DR. MARY ROSE HICKS PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	1430-057	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	40668	OTHER	WI	NATIONAL REGISTER

General Provider Information

NPI Number	:	1144434333
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY ROSE HICKS PH.D.

Provider Business Mailing Address
First Line	:	6215 S 39TH ST
Second Line	:
City	:	GREENFIELD
State	:	WI
Zip	:	53221-4521
Country	:	US
Telephone Number	:	414-737-4655
Fax Number	:

Provider Business Practice Location Address
First Line	:	9205 W CENTER ST
Second Line	:	SUITE 209
City	:	MILWAUKEE
State	:	WI
Zip	:	53222-4548
Country	:	US
Telephone Number	:	414-257-3044
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/09/2007
Last Update Date	:	07/08/2007

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