Provider Demographics
NPI:1619615762
Name:HICKS, MARISSA ELIZABETH EILEEN (MS)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:ELIZABETH EILEEN
Last Name:HICKS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:ELIZABETH
Other - Last Name:MILLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:109 FOUNTAIN BROOK CIR STE A
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511-3370
Mailing Address - Country:US
Mailing Address - Phone:919-238-9088
Mailing Address - Fax:919-375-2538
Practice Address - Street 1:109 FOUNTAIN BROOK CIR STE A
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-3370
Practice Address - Country:US
Practice Address - Phone:919-238-9088
Practice Address - Fax:919-375-2538
Is Sole Proprietor?:No
Enumeration Date:2022-05-26
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC30000706235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC30000706OtherNORTH CAROLINA BOARD OF EXAMINERS