Basic Information
| Provider Information | |||||||||
| NPI: | 1295284628 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HICKS | ||||||||
| FirstName: | DANIELLE | ||||||||
| MiddleName: | E. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 620 BYRON RD | ||||||||
| Address2: | |||||||||
| City: | HOWELL | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488431002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5175456000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 620 BYRON RD | ||||||||
| Address2: | |||||||||
| City: | HOWELL | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488431002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5175456000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2016 | ||||||||
| LastUpdateDate: | 12/08/2016 | ||||||||
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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 | 225100000X | 5501017703 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 26035 | MD | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 1282638 | TX | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | MI8976076 | 05 | MI | MEDICAID |