Provider Demographics
NPI:1114085339
Name:GOLLICKER, TOM (PT AIDE)
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:
Last Name:GOLLICKER
Suffix:
Gender:M
Credentials:PT AIDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 BLAIR PARK RD
Mailing Address - Street 2:PO BOX 1064
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-7435
Mailing Address - Country:US
Mailing Address - Phone:802-879-0909
Mailing Address - Fax:802-879-3095
Practice Address - Street 1:151 BLAIR PARK RD
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-7435
Practice Address - Country:US
Practice Address - Phone:802-879-0909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT041-0000469225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant