Provider Demographics
NPI:1801437157
Name:MICKETTI, JOSEPH (LMT)
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:
Last Name:MICKETTI
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1467 SISKIYOU BLVD # 53
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-2336
Mailing Address - Country:US
Mailing Address - Phone:541-482-0413
Mailing Address - Fax:
Practice Address - Street 1:279 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-2901
Practice Address - Country:US
Practice Address - Phone:541-482-0413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4348225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist