Provider Demographics
NPI:1679562284
Name:NICKS, GARY LOYD (PT)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:LOYD
Last Name:NICKS
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:PSC118
Mailing Address - Street 2:BOX 606
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09137
Mailing Address - Country:DE
Mailing Address - Phone:004-965-6169
Mailing Address - Fax:3183
Practice Address - Street 1:PSC118
Practice Address - Street 2:BOX 606
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09137
Practice Address - Country:DE
Practice Address - Phone:004-965-6169
Practice Address - Fax:3183
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000157969225100000X
IL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist