Provider Demographics
NPI:1912403049
Name:FLENNIKEN, JOEL DANIEL
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:DANIEL
Last Name:FLENNIKEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:532 GIBSON DR STE 100
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-5878
Mailing Address - Country:US
Mailing Address - Phone:916-546-2162
Mailing Address - Fax:
Practice Address - Street 1:2 BLACKBERRY LN
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-2300
Practice Address - Country:US
Practice Address - Phone:802-442-8525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-05
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502004108225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant