Basic Information
| Provider Information | |||||||||
| NPI: | 1093133100 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HICKS | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | VINCENT | ||||||||
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| Credential: | LCMHC, LCAS, CAMS-II | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 602368 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193500351 | ||||||||
| FaxNumber: | 9193507687 | ||||||||
| Practice Location | |||||||||
| Address1: | 3000 NEW BERN AVE | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276101231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193508000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2014 | ||||||||
| LastUpdateDate: | 05/23/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 25073 | NC | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | A10700 | NC | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YM0800X | 10700 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1093133100 | 05 | NC | MEDICAID |