Provider Demographics
NPI:1720553738
Name:KICK, MILDRED V (LMT)
Entity Type:Individual
Prefix:
First Name:MILDRED
Middle Name:V
Last Name:KICK
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:MILLIE KICK
Mailing Address - Street 2:N2610 ANTONY RD
Mailing Address - City:BANGOR
Mailing Address - State:WI
Mailing Address - Zip Code:54614-9315
Mailing Address - Country:US
Mailing Address - Phone:608-486-2927
Mailing Address - Fax:
Practice Address - Street 1:213 N BLACK RIVER ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:WI
Practice Address - Zip Code:54656-1529
Practice Address - Country:US
Practice Address - Phone:608-487-9990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-05
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI755-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist