Provider Demographics
NPI:1386460954
Name:MICKELSON, ROBBY JOHN (PTA)
Entity type:Individual
Prefix:
First Name:ROBBY
Middle Name:JOHN
Last Name:MICKELSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 SUMMER GATE WAY APT 12
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-5385
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:706-259-6426
Practice Address - Street 1:1212 BROADRICK DR
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-2503
Practice Address - Country:US
Practice Address - Phone:706-270-8008
Practice Address - Fax:706-259-6426
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-28
Last Update Date:2024-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA002859225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant