Provider Demographics
NPI:1922252626
Name:HICKS, MICHELLE J (LMP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:J
Last Name:HICKS
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 PROPER ST
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-5134
Mailing Address - Country:US
Mailing Address - Phone:662-415-9691
Mailing Address - Fax:
Practice Address - Street 1:1818 PROPER ST
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-5134
Practice Address - Country:US
Practice Address - Phone:662-415-9691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-06
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00024808225700000X
MSLMT1564225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist