Provider Demographics
NPI:1619146289
Name:HICKS, MARK BRYAN (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:BRYAN
Last Name:HICKS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 JEFFERSON TERRACE BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70560
Mailing Address - Country:US
Mailing Address - Phone:337-364-6366
Mailing Address - Fax:337-364-6166
Practice Address - Street 1:516 JEFFERSON TER
Practice Address - Street 2:SUITE 300
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70560-4948
Practice Address - Country:US
Practice Address - Phone:337-364-6366
Practice Address - Fax:337-364-6166
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-27
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA01915225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist