Provider Demographics
NPI:1659040269
Name:MIKULIC, MARTINA N/A (DPT)
Entity Type:Individual
Prefix:
First Name:MARTINA
Middle Name:N/A
Last Name:MIKULIC
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 NEW FIDELITY CT
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-2665
Mailing Address - Country:US
Mailing Address - Phone:570-842-9362
Mailing Address - Fax:
Practice Address - Street 1:106 S HANOVER ST
Practice Address - Street 2:
Practice Address - City:HUMMELSTOWN
Practice Address - State:PA
Practice Address - Zip Code:17036-2205
Practice Address - Country:US
Practice Address - Phone:717-974-3541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT029692225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist