Provider Demographics
NPI:1023426830
Name:HNILICKA, KEITH (LATC)
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:
Last Name:HNILICKA
Suffix:
Gender:M
Credentials:LATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4517 YORKSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-6559
Mailing Address - Country:US
Mailing Address - Phone:443-799-1109
Mailing Address - Fax:
Practice Address - Street 1:9880 GOOD LUCK RD
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-3423
Practice Address - Country:US
Practice Address - Phone:301-918-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-24
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00003702255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer