Provider Demographics
NPI:1811444847
Name:VERTHEIN, MICKAYLA
Entity type:Individual
Prefix:
First Name:MICKAYLA
Middle Name:
Last Name:VERTHEIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 S HOLMEN DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:HOLMEN
Mailing Address - State:WI
Mailing Address - Zip Code:54636-9467
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:464 S SAINT JOSEPH AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:ARCADIA
Practice Address - State:WI
Practice Address - Zip Code:54612-1401
Practice Address - Country:US
Practice Address - Phone:608-323-9998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2551-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant