Provider Demographics
NPI:1134788904
Name:HAWKS, RICKY LAMAR JR
Entity type:Individual
Prefix:
First Name:RICKY
Middle Name:LAMAR
Last Name:HAWKS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12981 MALLORY CIR APT 108
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-3818
Mailing Address - Country:US
Mailing Address - Phone:407-431-2157
Mailing Address - Fax:
Practice Address - Street 1:12315 LAKE UNDERHILL RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-4507
Practice Address - Country:US
Practice Address - Phone:407-964-1152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-06
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-21-49861103K00000X
FL19-88633103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty