Provider Demographics
NPI:1568782860
Name:LICKLIDER, THOMAS C II (CO)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:C
Last Name:LICKLIDER
Suffix:II
Gender:M
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 FOREST RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:NEBO
Mailing Address - State:NC
Mailing Address - Zip Code:28761-8708
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:132 FOREST RIDGE DR
Practice Address - Street 2:
Practice Address - City:NEBO
Practice Address - State:NC
Practice Address - Zip Code:28761-8708
Practice Address - Country:US
Practice Address - Phone:314-757-5395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-09
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist