Provider Demographics
NPI:1104456813
Name:KICOS, BROOKE ALIC (PT)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:ALIC
Last Name:KICOS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6200 OSCEOLA RD
Mailing Address - Street 2:
Mailing Address - City:MORROW
Mailing Address - State:OH
Mailing Address - Zip Code:45152-9757
Mailing Address - Country:US
Mailing Address - Phone:513-967-0877
Mailing Address - Fax:
Practice Address - Street 1:5640 COX SMITH RD
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-2210
Practice Address - Country:US
Practice Address - Phone:513-398-2881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-22
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH015571225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist