MEDICARE: KERRY JAMES HICKS SUDCC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	17453	CA
2	106S00000X	Behavior Technician	R1404530920	CA
3	171M00000X	Case Manager/Care Coordinator
4	101YA0400X	Addiction (Substance Use Disorder) Counselor		CA
5	175T00000X	Peer Specialist		CA

General Provider Information

NPI Number	:	1841941499
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KERRY JAMES HICKS SUDCC

Provider Business Mailing Address
First Line	:	44199 MONROE ST
Second Line	:
City	:	INDIO
State	:	CA
Zip	:	92201-3096
Country	:	US
Telephone Number	:	916-936-7712
Fax Number	:

Provider Business Practice Location Address
First Line	:	44199 MONROE ST STE B
Second Line	:
City	:	INDIO
State	:	CA
Zip	:	92201-3094
Country	:	US
Telephone Number	:	760-863-8074
Fax Number	:

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

Provider Enumeration Date	:	01/14/2022
Last Update Date	:	02/03/2026

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