Provider Demographics
NPI:1881662765
Name:MICK, ADAM TULLY (PT)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:TULLY
Last Name:MICK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5310 KIETZKE LN STE 104
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-2043
Mailing Address - Country:US
Mailing Address - Phone:775-348-8800
Mailing Address - Fax:775-348-8818
Practice Address - Street 1:9990 DOUBLE R BLVD STE 200
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89521-4833
Practice Address - Country:US
Practice Address - Phone:775-348-8800
Practice Address - Fax:775-348-8818
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1538225100000X
CA35436225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACK206YMedicare PIN
NV296531Medicare ID - Type Unspecified
CACK206ZMedicare PIN