Provider Demographics
NPI:1861603458
Name:HICKS, LORI ANN (MPT)
Entity type:Individual
Prefix:MS
First Name:LORI
Middle Name:ANN
Last Name:HICKS
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13050 SAN VICENTE BLVD
Mailing Address - Street 2:SUITE #119
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-4800
Mailing Address - Country:US
Mailing Address - Phone:310-312-0022
Mailing Address - Fax:
Practice Address - Street 1:13050 SAN VICENTE BLVD
Practice Address - Street 2:STE #119
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-4800
Practice Address - Country:US
Practice Address - Phone:310-312-0022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT24868225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist