Provider Demographics
NPI:1366020331
Name:HICKS, RAINA (LMT)
Entity Type:Individual
Prefix:
First Name:RAINA
Middle Name:
Last Name:HICKS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2157 M 119
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-9042
Mailing Address - Country:US
Mailing Address - Phone:231-590-9329
Mailing Address - Fax:
Practice Address - Street 1:2157 M 119
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-9042
Practice Address - Country:US
Practice Address - Phone:231-590-9329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-31
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501004162225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist