Provider Demographics
NPI:1174828255
Name:LICKEY, ALLYSON R (OT)
Entity Type:Individual
Prefix:
First Name:ALLYSON
Middle Name:R
Last Name:LICKEY
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3026 HIDDEN LAKE PT
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-4455
Mailing Address - Country:US
Mailing Address - Phone:270-316-1499
Mailing Address - Fax:270-691-8929
Practice Address - Street 1:1605 SCHERM RD
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-5300
Practice Address - Country:US
Practice Address - Phone:270-685-9499
Practice Address - Fax:270-685-9443
Is Sole Proprietor?:No
Enumeration Date:2011-01-20
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR4520225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP400035248Medicare PIN
INM400035243Medicare PIN