Provider Demographics
NPI:1447074984
Name:TICKNOR, MACY KAE (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:MACY
Middle Name:KAE
Last Name:TICKNOR
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69324 770TH ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:IA
Mailing Address - Zip Code:50837-8507
Mailing Address - Country:US
Mailing Address - Phone:712-590-0127
Mailing Address - Fax:
Practice Address - Street 1:1501 E 10TH ST
Practice Address - Street 2:
Practice Address - City:ATLANTIC
Practice Address - State:IA
Practice Address - Zip Code:50022-1936
Practice Address - Country:US
Practice Address - Phone:712-243-3250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-12
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA127298225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist