Provider Demographics
NPI:1104924257
Name:HICKS, ANTONETTE B (PT)
Entity type:Individual
Prefix:MRS
First Name:ANTONETTE
Middle Name:B
Last Name:HICKS
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 1:2763 UNIVERSITY ACRES DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32817-3015
Mailing Address - Country:US
Mailing Address - Phone:407-282-9869
Mailing Address - Fax:
Practice Address - Street 1:134 N OLD DIXIE HWY
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-4347
Practice Address - Country:US
Practice Address - Phone:352-751-6627
Practice Address - Fax:352-751-6628
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT0010599225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist