Provider Demographics
NPI:1790466167
Name:HICKS, TRACY LORRAINE (PT)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LORRAINE
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 1:204 KITTY HAWK CIR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-8581
Mailing Address - Country:US
Mailing Address - Phone:601-317-6608
Mailing Address - Fax:
Practice Address - Street 1:2628 COURTHOUSE CIR STE A
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9562
Practice Address - Country:US
Practice Address - Phone:601-932-0305
Practice Address - Fax:601-932-0360
Is Sole Proprietor?:No
Enumeration Date:2023-07-28
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT2437225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist