Provider Demographics
NPI:1679166904
Name:KICKLIGHTER, DWAYNE (PT)
Entity type:Individual
Prefix:MR
First Name:DWAYNE
Middle Name:
Last Name:KICKLIGHTER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7831 PARK LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75225-2000
Mailing Address - Country:US
Mailing Address - Phone:214-369-9905
Mailing Address - Fax:
Practice Address - Street 1:7831 PARK LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75225-2000
Practice Address - Country:US
Practice Address - Phone:214-369-9905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-17
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1178660225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist