Provider Demographics
NPI:1629624754
Name:MIKULSKI, ALICIA MARIE (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:MARIE
Last Name:MIKULSKI
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1356 WINANS AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-4748
Mailing Address - Country:US
Mailing Address - Phone:708-269-5583
Mailing Address - Fax:
Practice Address - Street 1:1 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-2345
Practice Address - Country:US
Practice Address - Phone:815-928-5415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-14
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer