Provider Demographics
NPI:1235603945
Name:MICKOW CE PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:MICKOW CE PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHELSEA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:847-748-8804
Mailing Address - Street 1:167 GLENDALE ST
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:IL
Mailing Address - Zip Code:60090-2933
Mailing Address - Country:US
Mailing Address - Phone:847-748-8804
Mailing Address - Fax:847-810-0046
Practice Address - Street 1:1200 OLD SKOKIE VALLEY RD
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-3036
Practice Address - Country:US
Practice Address - Phone:847-748-8804
Practice Address - Fax:847-810-0046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-15
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty