Provider Demographics
NPI:1487203220
Name:HICKS, TERESA R (CEO)
Entity type:Individual
Prefix:MS
First Name:TERESA
Middle Name:R
Last Name:HICKS
Suffix:
Gender:F
Credentials:CEO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3350 SWEETWATER RD APT 813
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-6573
Mailing Address - Country:US
Mailing Address - Phone:678-328-0107
Mailing Address - Fax:
Practice Address - Street 1:3350 SWEETWATER RD APT 813
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-6573
Practice Address - Country:US
Practice Address - Phone:678-328-0107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-04
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA059400425172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver