Provider Demographics
NPI:1730887126
Name:SMITH-HICKS, DOMINIQUE NICOLE
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:NICOLE
Last Name:SMITH-HICKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7817 MAPLE RUN CT
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21060-8668
Mailing Address - Country:US
Mailing Address - Phone:443-889-3921
Mailing Address - Fax:
Practice Address - Street 1:122 LANGLEY RD N
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21060-6531
Practice Address - Country:US
Practice Address - Phone:410-222-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-16
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDADT2897101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)