Provider Demographics
NPI:1710024385
Name:HICKS, MELISSA (PHD)
Entity type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:
Last Name:HICKS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 THE MASTERS CV
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31211-6029
Mailing Address - Country:US
Mailing Address - Phone:478-746-2127
Mailing Address - Fax:
Practice Address - Street 1:6601 ZEBULON RD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31220-7606
Practice Address - Country:US
Practice Address - Phone:478-320-7766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2227103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical