Provider Demographics
NPI:1477511525
Name:HICKS, ELIZABETH JOHNSON (PT)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:JOHNSON
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 1:21645 NW 87TH AVENUE RD
Mailing Address - Street 2:
Mailing Address - City:MICANOPY
Mailing Address - State:FL
Mailing Address - Zip Code:32667-7430
Mailing Address - Country:US
Mailing Address - Phone:352-466-0130
Mailing Address - Fax:352-529-0014
Practice Address - Street 1:37 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:FL
Practice Address - Zip Code:32696-2681
Practice Address - Country:US
Practice Address - Phone:352-528-0022
Practice Address - Fax:352-528-2878
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 362255A2300X
FLPT5183225100000X
FLRN1487192163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL890982200Medicaid
FL890982200Medicaid