Provider Demographics
NPI:1548021710
Name:MIKKELSON, CHASIDY (LMT)
Entity type:Individual
Prefix:
First Name:CHASIDY
Middle Name:
Last Name:MIKKELSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 E INVERNESS AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-7208
Mailing Address - Country:US
Mailing Address - Phone:602-348-1888
Mailing Address - Fax:
Practice Address - Street 1:2925 E INVERNESS AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-7208
Practice Address - Country:US
Practice Address - Phone:602-348-1888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-29390225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist