Healthcare Provider Details

I. General information

NPI: 1700663382
Provider Name (Legal Business Name): LAURA L. MIKA LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2023
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2298 BROCKETT RD
TUCKER GA
30084-4414
US

IV. Provider business mailing address

2298 BROCKETT RD
TUCKER GA
30084-4414
US

V. Phone/Fax

Practice location:
  • Phone: 706-425-8900
  • Fax:
Mailing address:
  • Phone: 706-425-8900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberMSW012165
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: