Provider Demographics
NPI:1053712711
Name:HICKS, VIVIAN (MA)
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:
Last Name:HICKS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:VIVIAN
Other - Middle Name:ILENE
Other - Last Name:RIVERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LMHCA
Mailing Address - Street 1:79 LILLY CREEK LN
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42629-7924
Mailing Address - Country:US
Mailing Address - Phone:253-625-0141
Mailing Address - Fax:253-302-5406
Practice Address - Street 1:79 LILLY CREEK LN
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:KY
Practice Address - Zip Code:42629-7924
Practice Address - Country:US
Practice Address - Phone:253-625-0141
Practice Address - Fax:253-302-5406
Is Sole Proprietor?:No
Enumeration Date:2014-09-11
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO 60457984101YA0400X
KY275012101YM0800X
WAMC60587450101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMC60587450OtherWASHINGTON STATE LMHCA
WALH60776174OtherMENTAL HEALTH COUNSELOR LICENSE
AL4397OtherALABAMA STATE LICENSE
WACO 60457984OtherWASHINGTON STATE CDPT
KY275012OtherKENTUCKY LPCC LICENSE