Provider Demographics
NPI:1114149382
Name:MICKO, KENNETH (PT)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:
Last Name:MICKO
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 1:620 STATE ROUTE 35
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07748-4224
Mailing Address - Country:US
Mailing Address - Phone:732-671-9560
Mailing Address - Fax:
Practice Address - Street 1:620 STATE ROUTE 35
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NJ
Practice Address - Zip Code:07748-4224
Practice Address - Country:US
Practice Address - Phone:732-671-9560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJPT40QA01024400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ316667Medicare ID - Type Unspecified