Provider Demographics
NPI:1922319581
Name:HICKMAN, KATHLEEN M (PT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:HICKMAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:M
Other - Last Name:HAAG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:6131 MILL CREEK BLVD
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-2723
Mailing Address - Country:US
Mailing Address - Phone:330-770-5263
Mailing Address - Fax:
Practice Address - Street 1:4329 MAHONING AVE NW STE B
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-1974
Practice Address - Country:US
Practice Address - Phone:330-847-7819
Practice Address - Fax:330-847-8192
Is Sole Proprietor?:No
Enumeration Date:2010-06-29
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT010250225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3092166Medicaid
OHBO4298781Medicare PIN