Provider Demographics
NPI:1194756957
Name:ICKES, DAWN-MARIE (MPT)
Entity type:Individual
Prefix:
First Name:DAWN-MARIE
Middle Name:
Last Name:ICKES
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30085 COMERCIO
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA MARGARITA
Mailing Address - State:CA
Mailing Address - Zip Code:92688-2106
Mailing Address - Country:US
Mailing Address - Phone:818-822-1600
Mailing Address - Fax:
Practice Address - Street 1:30085 COMERCIO
Practice Address - Street 2:
Practice Address - City:RANCHO SANTA MARGARITA
Practice Address - State:CA
Practice Address - Zip Code:92688-2106
Practice Address - Country:US
Practice Address - Phone:818-822-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22362225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist