Provider Demographics
NPI:1659677524
Name:MICKELSON, BETH (PT, DPT, ATC)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:MICKELSON
Suffix:
Gender:F
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 BON AIR RD
Mailing Address - Street 2:SUITE 129
Mailing Address - City:LARKSPUR
Mailing Address - State:CA
Mailing Address - Zip Code:94939-1143
Mailing Address - Country:US
Mailing Address - Phone:415-307-0866
Mailing Address - Fax:
Practice Address - Street 1:5 BON AIR RD
Practice Address - Street 2:SUITE 129
Practice Address - City:LARKSPUR
Practice Address - State:CA
Practice Address - Zip Code:94939-1143
Practice Address - Country:US
Practice Address - Phone:415-307-0866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-09
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA374002251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic