Provider Demographics
NPI:1871084814
Name:MIKULEC, AMY
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:MIKULEC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BANNER PHYSICAL THERAPY AND REHAB BOSWELL
Mailing Address - Street 2:10503 W THUNDERBIRD BLVD SUITE 263A
Mailing Address - City:SUN CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85351
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12930 CHIPPEWA RD
Practice Address - Street 2:
Practice Address - City:BRECKSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44141-2100
Practice Address - Country:US
Practice Address - Phone:216-409-1953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-25
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13677225100000X
OH017304225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ13677OtherMEDICARE
OH017304OtherOHIO PHYSICAL THERAPY LICENSE