Provider Demographics
NPI:1790712644
Name:MIKITA, STEPHEN G (RPT)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:G
Last Name:MIKITA
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10718 WHITE OAK AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-4628
Mailing Address - Country:US
Mailing Address - Phone:818-368-9484
Mailing Address - Fax:818-368-8054
Practice Address - Street 1:10718 WHITE OAK AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-4628
Practice Address - Country:US
Practice Address - Phone:818-368-9484
Practice Address - Fax:818-368-8054
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT28298225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19143Medicare ID - Type Unspecified