Provider Demographics
NPI:1356829782
Name:MICKALIS, MEREDITH A
Entity Type:Individual
Prefix:
First Name:MEREDITH
Middle Name:A
Last Name:MICKALIS
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 1:1440 HARDING PL APT 455
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-0041
Mailing Address - Country:US
Mailing Address - Phone:843-478-9629
Mailing Address - Fax:
Practice Address - Street 1:9131 BENFIELD RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-8791
Practice Address - Country:US
Practice Address - Phone:704-461-0073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-28
Last Update Date:2018-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP16225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist