MEDICARE: KERRY HICKETHIER PTA, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	8449	OR
2	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1912122201
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KERRY HICKETHIER PTA, ATC

Provider Business Mailing Address
First Line	:	8137 SWEETBRIER LN SE
Second Line	:	J-104
City	:	LACEY
State	:	WA
Zip	:	98513-8408
Country	:	US
Telephone Number	:	360-259-7729
Fax Number	:

Provider Business Practice Location Address
First Line	:	4200 6TH AVE SE
Second Line	:	SUITE 203
City	:	LACEY
State	:	WA
Zip	:	98503-1042
Country	:	US
Telephone Number	:	360-455-4448
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/13/2007
Last Update Date	:	09/11/2025

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