Provider Demographics
NPI:1912122201
Name:HICKETHIER, KERRY (PTA, ATC)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:HICKETHIER
Suffix:
Gender:F
Credentials:PTA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8137 SWEETBRIER LN SE
Mailing Address - Street 2:J-104
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98513-8408
Mailing Address - Country:US
Mailing Address - Phone:360-259-7729
Mailing Address - Fax:
Practice Address - Street 1:4200 6TH AVE SE
Practice Address - Street 2:SUITE 203
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1042
Practice Address - Country:US
Practice Address - Phone:360-455-4448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8449225200000X
2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Not Answered2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer