Provider Demographics
NPI:1245304971
Name:HICKOK, LARRY A (PT)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:A
Last Name:HICKOK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:24014 W RENWICK RD UNIT 206
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-8711
Mailing Address - Country:US
Mailing Address - Phone:800-974-4378
Mailing Address - Fax:630-515-1536
Practice Address - Street 1:831 DALLAS ST
Practice Address - Street 2:
Practice Address - City:CHETEK
Practice Address - State:WI
Practice Address - Zip Code:54728-5811
Practice Address - Country:US
Practice Address - Phone:800-974-4378
Practice Address - Fax:630-515-1536
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4639-24225100000X
WI4639-022251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40253000Medicaid
WI6405369OtherMEDICA
WI96462OtherSECURITY HEALTH PLAN
WI810587342022OtherWIS BCBS
WI40253000Medicaid
WI601601600OtherUS DEPT OF LABOR
WI810587342010OtherWIS BCBS
WI7398OtherGROUP HEALTH PLAN
WI41225700Medicaid
WI5336890002OtherADMINISTAR FEDERAL DME MEDICARE
WI6405370OtherMEDICA
WI7397OtherGROUP HEALTH PLAN
WI810587342010OtherWIS BCBS
WI7397OtherGROUP HEALTH PLAN