Healthcare Provider Details

I. General information

NPI: 1861105371
Provider Name (Legal Business Name): KELSEY MIKLUSCAK PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2022
Last Update Date: 12/29/2022
Certification Date: 12/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1707 NW SAINT LUCIE WEST BLVD STE 188
PORT SAINT LUCIE FL
34986-2521
US

IV. Provider business mailing address

313 RINGWOOD CIR
WINTER SPRINGS FL
32708-4959
US

V. Phone/Fax

Practice location:
  • Phone: 772-878-3322
  • Fax:
Mailing address:
  • Phone: 407-242-9478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT39588
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: