Basic Information
| Provider Information | |||||||||
| NPI: | 1467677856 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HICKS | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | BA,MHA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1351 NEWTOWN PIKE | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405111217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592531686 | ||||||||
| FaxNumber: | 8592542743 | ||||||||
| Practice Location | |||||||||
| Address1: | 3161 CUSTER DR | ||||||||
| Address2: | SUITE 4 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405174067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592531686 | ||||||||
| FaxNumber: | 8592542743 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 30615058 | 05 | KY | MEDICAID |