Provider Demographics
NPI:1629898523
Name:HICKS, DALLAS RYAN
Entity type:Individual
Prefix:
First Name:DALLAS
Middle Name:RYAN
Last Name:HICKS
Suffix:
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 1:2929 FLOYD AVE APT 225
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-8772
Mailing Address - Country:US
Mailing Address - Phone:916-514-2158
Mailing Address - Fax:
Practice Address - Street 1:2929 FLOYD AVE APT 225
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-8772
Practice Address - Country:US
Practice Address - Phone:916-514-2158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-15
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician