Provider Demographics
NPI:1376753343
Name:MIKELSON, PAUL S (OT)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:S
Last Name:MIKELSON
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:172 SCHILLER
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-2885
Mailing Address - Country:US
Mailing Address - Phone:630-758-9934
Mailing Address - Fax:
Practice Address - Street 1:360 W BUTTERFIELD RD
Practice Address - Street 2:#230
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126
Practice Address - Country:US
Practice Address - Phone:630-833-1800
Practice Address - Fax:630-833-1833
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056003882225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL977378OtherOT REGISTRATION NUMBER
IL056003882OtherSTATE LICENSE