Provider Demographics
NPI:1366816795
Name:HICKMAN, ELIZABETH (PT)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:
Last Name:HICKMAN
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 1:1029 YORK ST NE
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29801-4025
Mailing Address - Country:US
Mailing Address - Phone:803-502-1484
Mailing Address - Fax:803-502-1485
Practice Address - Street 1:1029 YORK ST NE
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-4025
Practice Address - Country:US
Practice Address - Phone:803-502-1484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-23
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305209419225100000X
NCP16355225100000X
225100000X
SC10116225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC09813OtherMEDICARE IDENTIFICATION NUMBER