Provider Demographics
NPI:1699983940
Name:HICKS, RANDALL BLAIR (PSYD)
Entity type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:BLAIR
Last Name:HICKS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 SOUTH STATE STREET
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18940-3507
Mailing Address - Country:US
Mailing Address - Phone:215-579-4116
Mailing Address - Fax:
Practice Address - Street 1:22 SOUTH STATE STREET
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:PA
Practice Address - Zip Code:18940-3507
Practice Address - Country:US
Practice Address - Phone:215-579-4116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS015295103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical