Provider Demographics
NPI:1114578721
Name:CHAMBERS, MIKAELA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MIKAELA
Middle Name:
Last Name:CHAMBERS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 PRESERVATION DR NE
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301-9667
Mailing Address - Country:US
Mailing Address - Phone:646-982-9502
Mailing Address - Fax:
Practice Address - Street 1:1412 W 3RD ST
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:VA
Practice Address - Zip Code:23901-2648
Practice Address - Country:US
Practice Address - Phone:434-392-1596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-25
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01866700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist