Provider Demographics
NPI:1649275421
Name:HICKS, DALE A (PHD)
Entity type:Individual
Prefix:DR
First Name:DALE
Middle Name:A
Last Name:HICKS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15961 N FLORIDA AVE
Mailing Address - Street 2:STE A
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33549-8101
Mailing Address - Country:US
Mailing Address - Phone:813-961-7544
Mailing Address - Fax:813-909-9038
Practice Address - Street 1:15961 N FLORIDA AVE
Practice Address - Street 2:STE A
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33549-8101
Practice Address - Country:US
Practice Address - Phone:813-961-7544
Practice Address - Fax:813-909-9038
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0002276103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75252Medicare ID - Type UnspecifiedBLUE CROSS BLUE SHIELD OF