Provider Demographics
NPI:1518486646
Name:HICKS, KIRSTY JOY (LMT)
Entity Type:Individual
Prefix:
First Name:KIRSTY
Middle Name:JOY
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 1:4434 COREY RD
Mailing Address - Street 2:
Mailing Address - City:CENTRAL POINT
Mailing Address - State:OR
Mailing Address - Zip Code:97502-9411
Mailing Address - Country:US
Mailing Address - Phone:541-821-3883
Mailing Address - Fax:
Practice Address - Street 1:820 CRATER LAKE AVE STE 113
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6581
Practice Address - Country:US
Practice Address - Phone:541-770-1606
Practice Address - Fax:541-770-1606
Is Sole Proprietor?:No
Enumeration Date:2017-09-09
Last Update Date:2017-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23646225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist