Provider Demographics
NPI:1487005872
Name:MIKLIK, KASEY EHREN (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:KASEY
Middle Name:EHREN
Last Name:MIKLIK
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2660 LAKE SHORE AVE
Mailing Address - Street 2:
Mailing Address - City:LITTLE CANADA
Mailing Address - State:MN
Mailing Address - Zip Code:55117-1320
Mailing Address - Country:US
Mailing Address - Phone:612-978-8393
Mailing Address - Fax:
Practice Address - Street 1:2660 LAKE SHORE AVE
Practice Address - Street 2:
Practice Address - City:LITTLE CANADA
Practice Address - State:MN
Practice Address - Zip Code:55117-1320
Practice Address - Country:US
Practice Address - Phone:612-978-8393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-27
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9926174400000X
MN105007174400000X
RIOT01543174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist