Provider Demographics
NPI:1245436898
Name:HICKERSON, DARRELL W JR (MPT)
Entity type:Individual
Prefix:
First Name:DARRELL
Middle Name:W
Last Name:HICKERSON
Suffix:JR
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 ENTERPRISE DR.
Mailing Address - Street 2:
Mailing Address - City:OAKBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523
Mailing Address - Country:US
Mailing Address - Phone:630-575-6250
Mailing Address - Fax:
Practice Address - Street 1:1300 VERTERANS BLVD.
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028
Practice Address - Country:US
Practice Address - Phone:636-931-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO112723225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist