Provider Demographics
NPI:1144434333
Name:HICKS, MARY ROSE (PHD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:ROSE
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 1:6215 S 39TH ST
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53221-4521
Mailing Address - Country:US
Mailing Address - Phone:414-737-4655
Mailing Address - Fax:
Practice Address - Street 1:9205 W CENTER ST
Practice Address - Street 2:SUITE 209
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-4548
Practice Address - Country:US
Practice Address - Phone:414-257-3044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1430-057103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40668OtherNATIONAL REGISTER