Provider Demographics
NPI:1699132050
Name:HICKS, KIRRA RACHEL (DPT)
Entity type:Individual
Prefix:MISS
First Name:KIRRA
Middle Name:RACHEL
Last Name:HICKS
Suffix:
Gender:F
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:PO BOX 645441 LOCKBOX 005441
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45264-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7424 BRIDGEPORT WAY W STE 101
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499
Practice Address - Country:US
Practice Address - Phone:253-582-8142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-15
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43610225100000X
WAPT60688010225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2071776Medicaid
WAG8961605Medicare PIN