Basic Information
| Provider Information | |||||||||
| NPI: | 1033364872 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HICKS-SYKES | ||||||||
| FirstName: | DERETHA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SYKES | ||||||||
| OtherFirstName: | MARY LEE | ||||||||
| OtherMiddleName: | D. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2303 VILLAGE DR | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 645064954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162718219 | ||||||||
| FaxNumber: | 8162322696 | ||||||||
| Practice Location | |||||||||
| Address1: | 904 S 10TH ST | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 645032405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162335188 | ||||||||
| FaxNumber: | 8162322696 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2008 | ||||||||
| LastUpdateDate: | 06/18/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 2004033766 | MO | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | F29A00013 | 01 | MEDICARE PTAN | OTHER | 1033364872 | 05 | MO | MEDICAID |