Provider Demographics
NPI:1659040269
Name:MIKULIC, MARTINA N/A (DPT)
Entity type:Individual
Prefix:
First Name:MARTINA
Middle Name:N/A
Last Name:MIKULIC
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 257
Mailing Address - Street 2:
Mailing Address - City:WILLARD
Mailing Address - State:MO
Mailing Address - Zip Code:65781-0257
Mailing Address - Country:US
Mailing Address - Phone:417-221-4667
Mailing Address - Fax:
Practice Address - Street 1:304 E JACKSON ST STE 2F
Practice Address - Street 2:
Practice Address - City:WILLARD
Practice Address - State:MO
Practice Address - Zip Code:65781-9472
Practice Address - Country:US
Practice Address - Phone:417-221-4667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-08
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT029692225100000X
MO2024025501225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist