Provider Demographics
NPI:1710163589
Name:HICKS, LISA A (PT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:HICKS
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 1:4301 COLFAX AVE APT 306
Mailing Address - Street 2:
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604-2832
Mailing Address - Country:US
Mailing Address - Phone:860-539-6045
Mailing Address - Fax:
Practice Address - Street 1:4301 COLFAX AVE
Practice Address - Street 2:#306
Practice Address - City:STUDIO CITY
Practice Address - State:CA
Practice Address - Zip Code:91604-2836
Practice Address - Country:US
Practice Address - Phone:860-539-6045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-11
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11026225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist