Healthcare Provider Details

I. General information

NPI: 1659209658
Provider Name (Legal Business Name): KELSEY ROSE MICKSCHL DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2540 COUNTY ROAD F E
WHITE BEAR TOWNSHIP MN
55110-3935
US

IV. Provider business mailing address

1045 COUNTY ROAD B W
ROSEVILLE MN
55113-4407
US

V. Phone/Fax

Practice location:
  • Phone: 651-410-6420
  • Fax:
Mailing address:
  • Phone: 651-410-6420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number9768
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: