Provider Demographics
NPI:1720652373
Name:MIKELS, KATELYN MARIE (PTA)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:MARIE
Last Name:MIKELS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 DWIGHT AVE
Mailing Address - Street 2:
Mailing Address - City:ENDICOTT
Mailing Address - State:NY
Mailing Address - Zip Code:13760-4045
Mailing Address - Country:US
Mailing Address - Phone:607-768-5283
Mailing Address - Fax:
Practice Address - Street 1:4102 VESTAL RD
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-3553
Practice Address - Country:US
Practice Address - Phone:607-772-1598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-18
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006946-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant