Provider Demographics
NPI:1831337245
Name:UPDEGRAFF, MICKEY L (PT)
Entity type:Individual
Prefix:MR
First Name:MICKEY
Middle Name:L
Last Name:UPDEGRAFF
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5410 GROVE MNR
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159-3533
Mailing Address - Country:US
Mailing Address - Phone:717-448-3107
Mailing Address - Fax:
Practice Address - Street 1:503 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:NEW CUMBERLAND
Practice Address - State:PA
Practice Address - Zip Code:17070-1972
Practice Address - Country:US
Practice Address - Phone:717-774-8210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-23
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT007394L225100000X
NY028252-01225100000X
FLPT36817225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist