Provider Demographics
NPI:1154496412
Name:WICKS, KEVIN DOUGLAS (PT)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:DOUGLAS
Last Name:WICKS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 OLD SUMMERWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34232-2940
Mailing Address - Country:US
Mailing Address - Phone:941-379-3343
Mailing Address - Fax:941-924-6670
Practice Address - Street 1:3568 CLARK RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34231-8408
Practice Address - Country:US
Practice Address - Phone:941-924-8868
Practice Address - Fax:941-924-6670
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT9887225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY905ZOtherMY BCBS NUMBER
FLY6827ZMedicare ID - Type UnspecifiedMY MEDICARE NUMBER