Provider Demographics
NPI:1699912295
Name:LICKWALA, HOLLY (PT)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:LICKWALA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1118 VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-1870
Mailing Address - Country:US
Mailing Address - Phone:360-736-8273
Mailing Address - Fax:360-736-5053
Practice Address - Street 1:1118 VIEW AVE
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-1870
Practice Address - Country:US
Practice Address - Phone:360-736-8273
Practice Address - Fax:360-736-5053
Is Sole Proprietor?:No
Enumeration Date:2009-01-19
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6214225100000X
WAPT60272758225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8910511Medicare PIN
WA0295449OtherL & I