Provider Demographics
NPI:1235965682
Name:MICKELSON, KIRA LYNN (PT, DPT)
Entity type:Individual
Prefix:
First Name:KIRA
Middle Name:LYNN
Last Name:MICKELSON
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 1:731 WILLIAMSON ST APT 341
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703-3545
Mailing Address - Country:US
Mailing Address - Phone:262-903-8541
Mailing Address - Fax:
Practice Address - Street 1:801 BRAXTON PL
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1415
Practice Address - Country:US
Practice Address - Phone:608-260-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-11
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16980-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist