Healthcare Provider Details

I. General information

NPI: 1245436898
Provider Name (Legal Business Name): DARRELL W HICKERSON JR. MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2007
Last Update Date: 10/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 VERTERANS BLVD.
FESTUS MO
63028
US

IV. Provider business mailing address

625 ENTERPRISE DR.
OAKBROOK IL
60523
US

V. Phone/Fax

Practice location:
  • Phone: 636-931-2100
  • Fax:
Mailing address:
  • Phone: 630-575-6250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number112723
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: