MEDICARE: ANDREA MICHAELSEN DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	080849	IA
2	225200000X	Physical Therapy Assistant	01152	IA

General Provider Information

NPI Number	:	1891122305
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA MICHAELSEN DPT

Provider Business Mailing Address
First Line	:	625 ENTERPRISE DR
Second Line	:
City	:	OAK BROOK
State	:	IL
Zip	:	60523-8813
Country	:	US
Telephone Number	:	630-575-1932
Fax Number	:	630-928-5032

Provider Business Practice Location Address
First Line	:	106 W WASHINGTON ST
Second Line	:	STE 2
City	:	JEFFERSON
State	:	IA
Zip	:	50129-1920
Country	:	US
Telephone Number	:	515-386-4192
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/28/2013
Last Update Date	:	12/02/2020

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