Provider Demographics
NPI:1336962927
Name:HICKS, KAITLYN AMBER (MT-BC)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:AMBER
Last Name:HICKS
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4105 46TH AVE NW APT 317
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-8557
Mailing Address - Country:US
Mailing Address - Phone:763-607-2348
Mailing Address - Fax:
Practice Address - Street 1:847 CIVIC CENTER DR NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901
Practice Address - Country:US
Practice Address - Phone:507-236-7793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19072225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist