Healthcare Provider Details

I. General information

NPI: 1851758692
Provider Name (Legal Business Name): MISS LAURA MIKOLAJCZYK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2016
Last Update Date: 06/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1845 GRANDSTAND PL
ELGIN IL
60123-6603
US

IV. Provider business mailing address

1845 GRANDSTAND PL
ELGIN IL
60123-6603
US

V. Phone/Fax

Practice location:
  • Phone: 847-695-0484
  • Fax:
Mailing address:
  • Phone: 847-695-0484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.011517
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: