Provider Demographics
NPI:1285856807
Name:MICEK, RENEE (PT)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:MICEK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5405 W. KERRY LANE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-4952
Mailing Address - Country:US
Mailing Address - Phone:623-362-3380
Mailing Address - Fax:
Practice Address - Street 1:5405 W. KERRY LANE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-4952
Practice Address - Country:US
Practice Address - Phone:623-362-3380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2075225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ139441Medicare PIN
AZ67173Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER