Provider Demographics
NPI:1013613470
Name:ULTIS, MIKALA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MIKALA
Middle Name:
Last Name:ULTIS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:656 W FINZEL RD
Mailing Address - Street 2:
Mailing Address - City:FROSTBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21532-4135
Mailing Address - Country:US
Mailing Address - Phone:301-697-8383
Mailing Address - Fax:
Practice Address - Street 1:11046 NEW GEORGES CREEK RD SW
Practice Address - Street 2:
Practice Address - City:FROSTBURG
Practice Address - State:MD
Practice Address - Zip Code:21532-1448
Practice Address - Country:US
Practice Address - Phone:240-284-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV004590225100000X
MD29308225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist