Provider Demographics
NPI:1437653649
Name:HICKS, TYRA JAMEESE (MA, QMHP)
Entity type:Individual
Prefix:
First Name:TYRA
Middle Name:JAMEESE
Last Name:HICKS
Suffix:
Gender:F
Credentials:MA, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23803-5763
Mailing Address - Country:US
Mailing Address - Phone:804-324-6514
Mailing Address - Fax:
Practice Address - Street 1:410 WALNUT ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-5763
Practice Address - Country:US
Practice Address - Phone:804-835-9959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-21
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty