Provider Demographics
NPI:1942785936
Name:HICKS, ELLINGTON KENNEDY II (LLMSW)
Entity type:Individual
Prefix:
First Name:ELLINGTON
Middle Name:KENNEDY
Last Name:HICKS
Suffix:II
Gender:M
Credentials:LLMSW
Other - Prefix:MR
Other - First Name:ELLINGTON
Other - Middle Name:K
Other - Last Name:HICKS
Other - Suffix:II
Other - Last Name Type:Professional Name
Other - Credentials:LLMSW
Mailing Address - Street 1:5200 KENSINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-2622
Mailing Address - Country:US
Mailing Address - Phone:313-909-4249
Mailing Address - Fax:
Practice Address - Street 1:1255 N OAKLAND BLVD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-1545
Practice Address - Country:US
Practice Address - Phone:248-406-0104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-26
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511028741041C0700X
MI68011028741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIH200213465305Medicaid