Provider Demographics
NPI:1194003814
Name:MICKEN, KATHRYN D (PTA)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:D
Last Name:MICKEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 RED LION BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:MILLINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:21651-1588
Mailing Address - Country:US
Mailing Address - Phone:410-924-7247
Mailing Address - Fax:
Practice Address - Street 1:124 RED LION BRANCH RD
Practice Address - Street 2:
Practice Address - City:MILLINGTON
Practice Address - State:MD
Practice Address - Zip Code:21651-1588
Practice Address - Country:US
Practice Address - Phone:410-924-7247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-29
Last Update Date:2016-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA3649225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant