Provider Demographics
NPI:1861644783
Name:HICKS, KIMBERLY (OTRL)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:HICKS
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23456 HAWTHORNE BLVD
Mailing Address - Street 2:SUITE 300B
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4716
Mailing Address - Country:US
Mailing Address - Phone:310-540-7381
Mailing Address - Fax:
Practice Address - Street 1:23456 HAWTHORNE BLVD
Practice Address - Street 2:SUITE 300B
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4716
Practice Address - Country:US
Practice Address - Phone:310-540-7381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-22
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9639225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist