Healthcare Provider Details

I. General information

NPI: 1639202518
Provider Name (Legal Business Name): MICHAEL PAUL MIKULSKI MFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 01/13/2022
Certification Date: 01/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 E FOOTHILL BLVD
PASADENA CA
91107-3406
US

IV. Provider business mailing address

11757 BROADFIELD DR
LA MIRADA CA
90638-1229
US

V. Phone/Fax

Practice location:
  • Phone: 626-590-2252
  • Fax:
Mailing address:
  • Phone: 562-949-8455
  • Fax: 562-949-4807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT45124
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: