MEDICARE: MR. KENNETH I. HICKS LICENSE CLINICAL SOC

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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1801102983
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KENNETH I. HICKS LICENSE CLINICAL SOC

Provider Business Mailing Address
First Line	:	14401 HARTSOOK ST APT 315
Second Line	:
City	:	SHERMAN OAKS
State	:	CA
Zip	:	91423-1041
Country	:	US
Telephone Number	:	818-788-8667
Fax Number	:

Provider Business Practice Location Address
First Line	:	14401 HARTSOOK ST APT 315
Second Line	:
City	:	SHERMAN OAKS
State	:	CA
Zip	:	91423-1041
Country	:	US
Telephone Number	:	818-788-8667
Fax Number	:

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

Provider Enumeration Date	:	08/26/2010
Last Update Date	:	08/31/2022

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