Provider Demographics
NPI:1003203431
Name:HICKS, ELLEN MYREE (ATC)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:MYREE
Last Name:HICKS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5939 FLANK CIR
Mailing Address - Street 2:
Mailing Address - City:PORT REPUBLIC
Mailing Address - State:VA
Mailing Address - Zip Code:24471-2231
Mailing Address - Country:US
Mailing Address - Phone:540-828-5368
Mailing Address - Fax:540-515-3763
Practice Address - Street 1:5939 FLANK CIR
Practice Address - Street 2:
Practice Address - City:PORT REPUBLIC
Practice Address - State:VA
Practice Address - Zip Code:24471-2231
Practice Address - Country:US
Practice Address - Phone:540-828-5368
Practice Address - Fax:540-515-3763
Is Sole Proprietor?:No
Enumeration Date:2015-04-23
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260003632255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer