Provider Demographics
NPI:1639214398
Name:ICKES, CAROL L (PT)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:L
Last Name:ICKES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6606 E. CARONDELET DRIVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-1328
Mailing Address - Country:US
Mailing Address - Phone:520-296-8513
Mailing Address - Fax:520-296-0075
Practice Address - Street 1:6606 E CARONDELET DRIVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-2119
Practice Address - Country:US
Practice Address - Phone:520-296-8513
Practice Address - Fax:520-296-0075
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3486225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ28053Medicare PIN