Healthcare Provider Details

I. General information

NPI: 1194942235
Provider Name (Legal Business Name): LEONARD ROBERT MIKULSKI L.C.S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 TEMPLE ST 3RD FLOOR
QUINCY MA
02169-5110
US

IV. Provider business mailing address

55 FLORENCE RD
WALTHAM MA
02453-1505
US

V. Phone/Fax

Practice location:
  • Phone: 617-471-8400
  • Fax:
Mailing address:
  • Phone: 781-899-3242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number207186
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number613
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: