Provider Demographics
NPI:1588854954
Name:ICKES, TIMOTHY R (MPT)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:R
Last Name:ICKES
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 687
Mailing Address - Street 2:
Mailing Address - City:GREENUP
Mailing Address - State:KY
Mailing Address - Zip Code:41144-0687
Mailing Address - Country:US
Mailing Address - Phone:606-473-1080
Mailing Address - Fax:606-473-5875
Practice Address - Street 1:1509 W MAIN ST STE 201
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:WV
Practice Address - Zip Code:25541-1105
Practice Address - Country:US
Practice Address - Phone:304-743-6995
Practice Address - Fax:304-743-5778
Is Sole Proprietor?:No
Enumeration Date:2007-07-31
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPT001895225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist