Provider Demographics
NPI:1912065848
Name:MICINSKI, ANNE MARIE (ATC, LAT)
Entity Type:Individual
Prefix:MS
First Name:ANNE
Middle Name:MARIE
Last Name:MICINSKI
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3718 FERN HILL DR
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-6265
Mailing Address - Country:US
Mailing Address - Phone:574-257-8512
Mailing Address - Fax:
Practice Address - Street 1:1005 N HICKORY RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46615-3723
Practice Address - Country:US
Practice Address - Phone:574-233-5754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000188A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer