Provider Demographics
NPI:1760063911
Name:HICKS, JOSHUA DANIEL
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:DANIEL
Last Name:HICKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 RED BIRD ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:IL
Mailing Address - Zip Code:62294-2161
Mailing Address - Country:US
Mailing Address - Phone:217-690-0435
Mailing Address - Fax:
Practice Address - Street 1:311 RED BIRD ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:IL
Practice Address - Zip Code:62294-2161
Practice Address - Country:US
Practice Address - Phone:217-690-0435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer