Provider Demographics
NPI:1720235690
Name:MICKELSEN, MELINDA RAQUEL (MS, ORT/L)
Entity Type:Individual
Prefix:MS
First Name:MELINDA
Middle Name:RAQUEL
Last Name:MICKELSEN
Suffix:
Gender:F
Credentials:MS, ORT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 LANCASSANGE DR
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-5454
Mailing Address - Country:US
Mailing Address - Phone:502-645-0564
Mailing Address - Fax:
Practice Address - Street 1:304 LANCASSANGE DR
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-5454
Practice Address - Country:US
Practice Address - Phone:502-645-0564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-22
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-R1598225X00000X
IN31004140A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist