Provider Demographics
NPI:1629207964
Name:KICKLIGHTER, TAZ HUNTER (MS, ATC)
Entity Type:Individual
Prefix:
First Name:TAZ
Middle Name:HUNTER
Last Name:KICKLIGHTER
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7455 SALMON LN.
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-5530
Mailing Address - Country:US
Mailing Address - Phone:770-862-0494
Mailing Address - Fax:
Practice Address - Street 1:7300 REINHARDT COLLEGE CIR
Practice Address - Street 2:
Practice Address - City:WALESKA
Practice Address - State:GA
Practice Address - Zip Code:30183-2981
Practice Address - Country:US
Practice Address - Phone:770-720-9226
Practice Address - Fax:770-720-5622
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-08
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6282255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer