Provider Demographics
NPI:1295040186
Name:TICE, CORRIE LYNN GRAVES (PT)
Entity Type:Individual
Prefix:MS
First Name:CORRIE LYNN
Middle Name:GRAVES
Last Name:TICE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:CORRIE
Other - Middle Name:LYNN
Other - Last Name:GRAVES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:201 NE 83RD TER
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64118-1253
Mailing Address - Country:US
Mailing Address - Phone:816-420-9901
Mailing Address - Fax:816-420-9901
Practice Address - Street 1:2727 TRACY AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64109-1243
Practice Address - Country:US
Practice Address - Phone:816-889-3502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-16
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20000152219225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist