Provider Demographics
NPI:1629660196
Name:HICKS-GREEN, GRACE
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:HICKS-GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 SETON CENTER PKWY STE 175
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-4107
Mailing Address - Country:US
Mailing Address - Phone:512-439-1940
Mailing Address - Fax:
Practice Address - Street 1:4700 SETON CENTER PKWY
Practice Address - Street 2:STE. 175
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-4107
Practice Address - Country:US
Practice Address - Phone:512-439-1940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-06
Last Update Date:2021-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant