Provider Demographics
NPI:1053759597
Name:HICKS, SHANNA M (MS)
Entity type:Individual
Prefix:MISS
First Name:SHANNA
Middle Name:M
Last Name:HICKS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 BURD ST
Mailing Address - Street 2:
Mailing Address - City:NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10960-3205
Mailing Address - Country:US
Mailing Address - Phone:845-353-2350
Mailing Address - Fax:845-353-2397
Practice Address - Street 1:21 BURD ST
Practice Address - Street 2:
Practice Address - City:NYACK
Practice Address - State:NY
Practice Address - Zip Code:10960-3205
Practice Address - Country:US
Practice Address - Phone:845-353-2350
Practice Address - Fax:845-353-2397
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-06
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY703307131174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist