Basic Information
| Provider Information | |||||||||
| NPI: | 1063742955 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HICKS | ||||||||
| FirstName: | MOLLY | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | MINK | ||||||||
| OtherFirstName: | MOLLY | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1900 MIDLAND TRL | ||||||||
| Address2: | SUITE 1 AND 2 | ||||||||
| City: | SHELBYVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 400658141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026331007 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1900 MIDLAND TRL | ||||||||
| Address2: | SUITE 1 AND 2 | ||||||||
| City: | SHELBYVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 400658141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026331007 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2009 | ||||||||
| LastUpdateDate: | 12/01/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | BOTOCT00210727 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.