Provider Demographics
NPI:1063983781
Name:HICKS, EBONY (LLMSW)
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:HICKS
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:EBONY
Other - Middle Name:
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LLBSW
Mailing Address - Street 1:2400 SCIENCE PKWY
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-2560
Mailing Address - Country:US
Mailing Address - Phone:517-374-8066
Mailing Address - Fax:
Practice Address - Street 1:2400 SCIENCE PKWY
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-2560
Practice Address - Country:US
Practice Address - Phone:517-374-8066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-06
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI6851113982104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No104100000XBehavioral Health & Social Service ProvidersSocial Worker