Provider Demographics
NPI:1801020417
Name:HICKS, KELLI M (LMT)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:M
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 1:75-5591 PALANI RD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-3631
Mailing Address - Country:US
Mailing Address - Phone:808-327-9845
Mailing Address - Fax:808-329-9038
Practice Address - Street 1:75-5591 PALANI RD
Practice Address - Street 2:SUITE 207
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-3631
Practice Address - Country:US
Practice Address - Phone:808-327-9845
Practice Address - Fax:808-329-9038
Is Sole Proprietor?:No
Enumeration Date:2009-05-11
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI11115225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist