Provider Demographics
NPI:1376625988
Name:DANIEL, MIKKI L (PT)
Entity Type:Individual
Prefix:MS
First Name:MIKKI
Middle Name:L
Last Name:DANIEL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:MIKKI
Other - Middle Name:L
Other - Last Name:DANIEL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:5411 I 55 N
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-3616
Mailing Address - Country:US
Mailing Address - Phone:601-940-5906
Mailing Address - Fax:601-510-9012
Practice Address - Street 1:1901 MISSION 66
Practice Address - Street 2:SUITE A
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-3711
Practice Address - Country:US
Practice Address - Phone:601-638-4076
Practice Address - Fax:601-638-4979
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT 3064225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00121389Medicaid
MS000050976OtherBLUE CROSS BLUE SHIELD
MS7589031OtherAETNA
MS00121389Medicaid