1184378259 NPI number — DR. KIMBERLY L HICKS PT, DPT

Table of content: DR. KIMBERLY L HICKS PT, DPT (NPI 1184378259)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184378259 NPI number — DR. KIMBERLY L HICKS PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HICKS
Provider First Name:
KIMBERLY
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184378259
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1760 STONEGATE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTGOMERY
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60538-3338
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
58 W PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUGAR GROVE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60554-2208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-537-3445
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/08/2022

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  070026285 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)