Healthcare Provider Details

I. General information

NPI: 1578473088
Provider Name (Legal Business Name): BLAKE HICKS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1169 ROBERTSON RD S
MURRAY KY
42071-4649
US

IV. Provider business mailing address

PO BOX 932184
ATLANTA GA
31193-2184
US

V. Phone/Fax

Practice location:
  • Phone: 904-618-3778
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number302468
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: