Provider Demographics
NPI:1235243841
Name:HICKS, STACEY (PT)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:HICKS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:NH
Mailing Address - Zip Code:03584-3027
Mailing Address - Country:US
Mailing Address - Phone:603-586-4100
Mailing Address - Fax:603-444-0473
Practice Address - Street 1:55 MAIN ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:NH
Practice Address - Zip Code:03584-3027
Practice Address - Country:US
Practice Address - Phone:603-586-4100
Practice Address - Fax:603-444-0473
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1987174400000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30390311Medicaid
NH30390311Medicaid