Provider Demographics
NPI:1114811577
Name:HICKS, AUTUMN ANN MARIE
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:ANN MARIE
Last Name:HICKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANDY
Other - Middle Name:
Other - Last Name:HICKS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:65 13TH ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-4361
Mailing Address - Country:US
Mailing Address - Phone:248-854-0025
Mailing Address - Fax:
Practice Address - Street 1:195 HURON BLVD
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:MI
Practice Address - Zip Code:48040-1421
Practice Address - Country:US
Practice Address - Phone:989-401-2244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-09
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician