Provider Demographics
NPI:1568675189
Name:GALICKI, JONATHAN JAMES (PTA)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:JAMES
Last Name:GALICKI
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17220 WARRIOR DR
Mailing Address - Street 2:
Mailing Address - City:HOWARD CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49329-9338
Mailing Address - Country:US
Mailing Address - Phone:616-617-6561
Mailing Address - Fax:
Practice Address - Street 1:3505 LAKE LYNDA DIVE
Practice Address - Street 2:SUITE 207
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817
Practice Address - Country:US
Practice Address - Phone:877-896-3660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160-002759225200000X
GAPTA001235225200000X
NVA-0411225200000X
TX2033181225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant