Provider Demographics
NPI:1558102111
Name:HICKCOX, ETHAN JOSEPH (DPT)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:JOSEPH
Last Name:HICKCOX
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3148 BRONSON RD
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54495-8333
Mailing Address - Country:US
Mailing Address - Phone:651-900-1367
Mailing Address - Fax:
Practice Address - Street 1:1041 HILL ST
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-5202
Practice Address - Country:US
Practice Address - Phone:715-421-7474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16746-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist