Provider Demographics
NPI:1982012282
Name:ROSS, MIKAELA M (DPT)
Entity Type:Individual
Prefix:
First Name:MIKAELA
Middle Name:M
Last Name:ROSS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MIKAELA
Other - Middle Name:M
Other - Last Name:SHAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:121 EVERETT RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-1474
Mailing Address - Country:US
Mailing Address - Phone:518-489-2663
Mailing Address - Fax:
Practice Address - Street 1:121 EVERETT RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-1474
Practice Address - Country:US
Practice Address - Phone:518-489-2663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-30
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033834225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04038684Medicaid
NY033834OtherNY LICENSE