Provider Demographics
NPI:1073222006
Name:MICKELSEN, DAVID (PT)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:MICKELSEN
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 1:531 N ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:CA
Mailing Address - Zip Code:95648-1523
Mailing Address - Country:US
Mailing Address - Phone:321-362-8794
Mailing Address - Fax:
Practice Address - Street 1:531 N ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:CA
Practice Address - Zip Code:95648-1523
Practice Address - Country:US
Practice Address - Phone:321-362-8794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-17
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT295568225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist