Provider Demographics
NPI:1326833955
Name:HICKS, LYDIA MARIE
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:MARIE
Last Name:HICKS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4234 CASCADE RD SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8384
Mailing Address - Country:US
Mailing Address - Phone:877-654-4144
Mailing Address - Fax:
Practice Address - Street 1:6688 S PATIENCE
Practice Address - Street 2:
Practice Address - City:IDLEWILD
Practice Address - State:MI
Practice Address - Zip Code:49642-8562
Practice Address - Country:US
Practice Address - Phone:909-533-0963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-14
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician