Provider Demographics
NPI:1316285455
Name:HICKLE, SHALON (DPT)
Entity type:Individual
Prefix:
First Name:SHALON
Middle Name:
Last Name:HICKLE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 FITNESS LN
Mailing Address - Street 2:
Mailing Address - City:BERKELEY SPRINGS
Mailing Address - State:WV
Mailing Address - Zip Code:25411-7080
Mailing Address - Country:US
Mailing Address - Phone:304-258-1300
Mailing Address - Fax:304-258-1400
Practice Address - Street 1:8543 WINCHESTER AVE
Practice Address - Street 2:
Practice Address - City:INWOOD
Practice Address - State:WV
Practice Address - Zip Code:25428-4022
Practice Address - Country:US
Practice Address - Phone:304-229-1010
Practice Address - Fax:304-229-5151
Is Sole Proprietor?:No
Enumeration Date:2013-01-24
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT016481225100000X
VA2305207786225100000X
WV003531225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV003531OtherPHYSICAL THERAPY