Provider Demographics
NPI:1770131146
Name:GREGORY-MIKULICIC, MICHELLE (LMT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:GREGORY-MIKULICIC
Suffix:
Gender:
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4307 ALBANY POST RD
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12538-3601
Mailing Address - Country:US
Mailing Address - Phone:845-233-5672
Mailing Address - Fax:
Practice Address - Street 1:4307 ALBANY POST RD
Practice Address - Street 2:
Practice Address - City:HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:12538-3601
Practice Address - Country:US
Practice Address - Phone:845-233-5672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-29
Last Update Date:2025-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA91259225700000X
NY0005820-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist