Provider Demographics
NPI:1598099749
Name:MICKAS, MATTHEW (DPT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:MICKAS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15400 E 127TH ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:LEMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60439-8408
Mailing Address - Country:US
Mailing Address - Phone:630-257-9787
Mailing Address - Fax:630-257-9947
Practice Address - Street 1:15400 E 127TH ST
Practice Address - Street 2:SUITE C
Practice Address - City:LEMONT
Practice Address - State:IL
Practice Address - Zip Code:60439-8408
Practice Address - Country:US
Practice Address - Phone:630-257-9787
Practice Address - Fax:630-257-9947
Is Sole Proprietor?:No
Enumeration Date:2009-09-21
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-017414225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist