Provider Demographics
NPI:1003512385
Name:MICKEY, RENISE (MT)
Entity Type:Individual
Prefix:
First Name:RENISE
Middle Name:
Last Name:MICKEY
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7550 COLUMBIA AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:IN
Mailing Address - Zip Code:46324-3059
Mailing Address - Country:US
Mailing Address - Phone:219-501-6575
Mailing Address - Fax:
Practice Address - Street 1:9219 INDIANAPOLIS BLVD STE 204
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IN
Practice Address - Zip Code:46322-2573
Practice Address - Country:US
Practice Address - Phone:219-501-6575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-07
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT21806622225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist