Provider Demographics
NPI:1699108464
Name:KALICKI, CAREY E
Entity type:Individual
Prefix:
First Name:CAREY
Middle Name:E
Last Name:KALICKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CAREY
Other - Middle Name:E
Other - Last Name:DAWLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6344 PERSHING BLVD
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-3275
Mailing Address - Country:US
Mailing Address - Phone:262-344-1785
Mailing Address - Fax:
Practice Address - Street 1:6344 PERSHING BLVD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-3275
Practice Address - Country:US
Practice Address - Phone:262-344-1785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-15
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2064-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant