Provider Demographics
NPI:1841897683
Name:MIKESELL, ADDIE (PT, DPT)
Entity type:Individual
Prefix:MRS
First Name:ADDIE
Middle Name:
Last Name:MIKESELL
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 RUSH RD
Mailing Address - Street 2:
Mailing Address - City:NEW MADISON
Mailing Address - State:OH
Mailing Address - Zip Code:45346-8710
Mailing Address - Country:US
Mailing Address - Phone:937-459-6733
Mailing Address - Fax:
Practice Address - Street 1:750 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:OH
Practice Address - Zip Code:45331-1312
Practice Address - Country:US
Practice Address - Phone:937-547-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-05
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH015055225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist