Provider Demographics
NPI:1093214371
Name:MIKUSKI, MELISSA M (RPT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:M
Last Name:MIKUSKI
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4219 OWL CREEK DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53718-4409
Mailing Address - Country:US
Mailing Address - Phone:860-459-9991
Mailing Address - Fax:
Practice Address - Street 1:718 JUPITER DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53718-2950
Practice Address - Country:US
Practice Address - Phone:608-663-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-01
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12206-242251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI12206-24OtherPHYSICAL THERAPIST