Provider Demographics
NPI:1639702897
Name:HICKS, KATHY L (LMT)
Entity Type:Individual
Prefix:MS
First Name:KATHY
Middle Name:L
Last Name:HICKS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1086 DONAL DR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44907-2648
Mailing Address - Country:US
Mailing Address - Phone:419-270-5053
Mailing Address - Fax:
Practice Address - Street 1:1086 DONAL DR
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44907-2648
Practice Address - Country:US
Practice Address - Phone:419-270-5053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-17
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH020504225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH020504Medicaid