Basic Information
| Provider Information | |||||||||
| NPI: | 1184167686 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THICKLIN | ||||||||
| FirstName: | DETRAVES | ||||||||
| MiddleName: | NEVILLE | ||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8823 PRODUCTION LN | ||||||||
| Address2: | |||||||||
| City: | OOLTEWAH | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373636511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232387217 | ||||||||
| FaxNumber: | 4233628684 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 WALMART DR | ||||||||
| Address2: | STE 100 | ||||||||
| City: | SODDY DAISY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373795022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233329490 | ||||||||
| FaxNumber: | 4233323817 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2016 | ||||||||
| LastUpdateDate: | 12/01/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.