Provider Demographics
NPI:1871204453
Name:HICKS, LATRON P
Entity type:Individual
Prefix:MR
First Name:LATRON
Middle Name:P
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 1:9947 PIPESTONE ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89141-8667
Mailing Address - Country:US
Mailing Address - Phone:702-601-4647
Mailing Address - Fax:
Practice Address - Street 1:4375 LAS VEGAS BLVD N
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89115-0587
Practice Address - Country:US
Practice Address - Phone:702-601-4647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty