Provider Demographics
NPI:1669910295
Name:HICKS, MARIA (LAC)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:HICKS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10701 NW COPELAND ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-6141
Mailing Address - Country:US
Mailing Address - Phone:503-548-7170
Mailing Address - Fax:
Practice Address - Street 1:10701 NW COPELAND ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-6141
Practice Address - Country:US
Practice Address - Phone:503-548-7170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-02
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC180003171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist