Provider Demographics
NPI:1013374438
Name:HICKS, KELLY (COTA/L)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:HICKS
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1806 LAKE TEXOMA CIR
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75002-4840
Mailing Address - Country:US
Mailing Address - Phone:419-908-5376
Mailing Address - Fax:
Practice Address - Street 1:1806 LAKE TEXOMA CIR
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75002-4840
Practice Address - Country:US
Practice Address - Phone:419-908-5376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-15
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX216528224Z00000X
KS18-01276224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant