Provider Demographics
NPI:1659548063
Name:MICKELSON, MANDY (PTA)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:MICKELSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6232 STATE HIGHWAY 16
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:WI
Mailing Address - Zip Code:54656-3505
Mailing Address - Country:US
Mailing Address - Phone:608-343-1236
Mailing Address - Fax:
Practice Address - Street 1:2501 SHELBY RD
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-8037
Practice Address - Country:US
Practice Address - Phone:608-788-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1409-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant