Provider Demographics
NPI:1720865827
Name:ROSENOW, MICA J (LMT)
Entity Type:Individual
Prefix:
First Name:MICA
Middle Name:J
Last Name:ROSENOW
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2850 MEDFORD AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46222-2252
Mailing Address - Country:US
Mailing Address - Phone:417-355-0358
Mailing Address - Fax:
Practice Address - Street 1:2850 MEDFORD AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46222-2252
Practice Address - Country:US
Practice Address - Phone:417-355-0358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-12
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT22007113225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist