Provider Demographics
NPI:1114206182
Name:MICKELS, MARY
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:MICKELS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5505 GROVER ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68106-3718
Mailing Address - Country:US
Mailing Address - Phone:402-551-4970
Mailing Address - Fax:402-558-0227
Practice Address - Street 1:5505 GROVER ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68106-3718
Practice Address - Country:US
Practice Address - Phone:402-551-4970
Practice Address - Fax:402-558-0227
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-09
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2496225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist