Provider Demographics
NPI:1154699122
Name:HICKS, BETHANY ERIN (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:ERIN
Last Name:HICKS
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 BRITTS DR
Mailing Address - Street 2:
Mailing Address - City:LENOIR CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37772-6992
Mailing Address - Country:US
Mailing Address - Phone:865-789-0854
Mailing Address - Fax:
Practice Address - Street 1:629 GALLAHER RD
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:TN
Practice Address - Zip Code:37763-4215
Practice Address - Country:US
Practice Address - Phone:865-376-3416
Practice Address - Fax:865-376-3532
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-06
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3267235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist