Provider Demographics
NPI:1114178696
Name:MIKELSON, HEATHER M (DT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:M
Last Name:MIKELSON
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1470 E 1200 NORTH RD
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:IL
Mailing Address - Zip Code:60953-6256
Mailing Address - Country:US
Mailing Address - Phone:815-683-2107
Mailing Address - Fax:
Practice Address - Street 1:1470 E 1200 NORTH RD
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:IL
Practice Address - Zip Code:60953-6256
Practice Address - Country:US
Practice Address - Phone:815-683-2107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-02
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist