Provider Demographics
NPI:1396186045
Name:MIKESELL, CHAD T (PT)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:T
Last Name:MIKESELL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 OAKMONT LN STE 600C
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5548
Mailing Address - Country:US
Mailing Address - Phone:630-575-6200
Mailing Address - Fax:
Practice Address - Street 1:3601 30TH AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1695
Practice Address - Country:US
Practice Address - Phone:262-657-7071
Practice Address - Fax:262-657-0632
Is Sole Proprietor?:No
Enumeration Date:2013-07-10
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12437225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1396186045Medicaid
WIK400093822Medicare PIN