Provider Demographics
NPI:1952856445
Name:STAAL, MICKAYLA
Entity Type:Individual
Prefix:
First Name:MICKAYLA
Middle Name:
Last Name:STAAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3946 GLENVIEW CT
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426-8400
Mailing Address - Country:US
Mailing Address - Phone:616-647-7768
Mailing Address - Fax:
Practice Address - Street 1:3946 GLENVIEW CT
Practice Address - Street 2:
Practice Address - City:HUDSONVILLE
Practice Address - State:MI
Practice Address - Zip Code:49426-8400
Practice Address - Country:US
Practice Address - Phone:616-647-7768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-24
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X, 390200000X
MI26010021062255A2300X
FLPT39736225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program