Healthcare Provider Details

I. General information

NPI: 1578922563
Provider Name (Legal Business Name): ERIC MIKLUSICAK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2016
Last Update Date: 02/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 E CANAL DR
TURLOCK CA
95380-3936
US

IV. Provider business mailing address

420 E CANAL DR
TURLOCK CA
95380-3936
US

V. Phone/Fax

Practice location:
  • Phone: 209-669-2583
  • Fax:
Mailing address:
  • Phone: 209-669-2583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number85107
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: