MEDICARE: MR. JONATHAN DANIEL MIKULAK L.S.W.

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	104100000X	Social Worker	SW126542	PA

General Provider Information

NPI Number	:	1720386337
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JONATHAN DANIEL MIKULAK L.S.W.

Provider Business Mailing Address
First Line	:	6134 HALLWOOD DR
Second Line	:
City	:	VERONA
State	:	PA
Zip	:	15147-2523
Country	:	US
Telephone Number	:	412-996-6818
Fax Number	:

Provider Business Practice Location Address
First Line	:	3063 FREEPORT RD
Second Line	:	SUITE B
City	:	NATRONA HEIGHTS
State	:	PA
Zip	:	15065-1967
Country	:	US
Telephone Number	:	724-766-9238
Fax Number	:	724-226-0931

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

Provider Enumeration Date	:	03/06/2011
Last Update Date	:	03/06/2011

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