Provider Demographics
NPI:1154314003
Name:HICKERNELL, ELISE L (PT, ATC)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:L
Last Name:HICKERNELL
Suffix:
Gender:F
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8701 TROY PIKE STE 220
Mailing Address - Street 2:
Mailing Address - City:HUBER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:45424-1188
Mailing Address - Country:US
Mailing Address - Phone:937-558-3338
Mailing Address - Fax:937-558-3327
Practice Address - Street 1:8701 TROY PIKE STE 220
Practice Address - Street 2:
Practice Address - City:HUBER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:45424-1188
Practice Address - Country:US
Practice Address - Phone:937-558-3338
Practice Address - Fax:937-558-3327
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT017542225100000X
PADAPT002641225100000X
PART0038412255A2300X
OHPT016068225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101663154 0004Medicaid
PA101663154 0005Medicaid
PA265998OtherHEALTH AMERICA
PA101663154 0003Medicaid
PAP00245501OtherRAILROAD
PA101663154 0001Medicaid
PA101663154 0002Medicaid
PA101663154 0006Medicaid
PA101663154 0007Medicaid
PA1746213OtherHIGHMARK
PA101663154 0001Medicaid