Provider Demographics
NPI:1255924411
Name:HICKS, SAMUEL LEE JR
Entity type:Individual
Prefix:PROF
First Name:SAMUEL
Middle Name:LEE
Last Name:HICKS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2835 LOOKOVER DR LOT 45
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45251-3012
Mailing Address - Country:US
Mailing Address - Phone:513-544-5827
Mailing Address - Fax:
Practice Address - Street 1:2835 LOOKOVER DR LOT 45
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45251-3012
Practice Address - Country:US
Practice Address - Phone:513-544-5827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-18
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator