Provider Demographics
NPI:1700150273
Name:MIKKELSON, WINNIE L (LPT)
Entity Type:Individual
Prefix:
First Name:WINNIE
Middle Name:L
Last Name:MIKKELSON
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 ANDERSON AVE
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28144-2940
Mailing Address - Country:US
Mailing Address - Phone:704-637-9517
Mailing Address - Fax:
Practice Address - Street 1:1508 W INNES ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-2504
Practice Address - Country:US
Practice Address - Phone:704-630-9656
Practice Address - Fax:704-630-9658
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-01
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7843225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist