Provider Demographics
NPI:1275568438
Name:HICKS, KRISTEN ROBERTSON (MPT)
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:ROBERTSON
Last Name:HICKS
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:MISS
Other - First Name:KRISTEN
Other - Middle Name:KATHLEEN
Other - Last Name:ROBERTSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:2000 BREMO RD STE 202
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-2440
Mailing Address - Country:US
Mailing Address - Phone:804-285-0148
Mailing Address - Fax:804-673-6026
Practice Address - Street 1:2000 BREMO RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-2440
Practice Address - Country:US
Practice Address - Phone:804-285-0148
Practice Address - Fax:804-673-6026
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305202458225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist