Provider Demographics
NPI:1689483869
Name:HICKS, THERESA DIANE
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:DIANE
Last Name:HICKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5028 W HERNDON AVE APT 101
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93722-8431
Mailing Address - Country:US
Mailing Address - Phone:559-722-4766
Mailing Address - Fax:
Practice Address - Street 1:49774 ROAD 426 STE D
Practice Address - Street 2:
Practice Address - City:OAKHURST
Practice Address - State:CA
Practice Address - Zip Code:93644-8691
Practice Address - Country:US
Practice Address - Phone:559-395-0453
Practice Address - Fax:559-683-6499
Is Sole Proprietor?:No
Enumeration Date:2025-01-02
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator