Healthcare Provider Details

I. General information

NPI: 1013666890
Provider Name (Legal Business Name): YIANNI MIKALIS LCPC, LCPAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2022
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 S WOLFE ST
BALTIMORE MD
21231-3034
US

IV. Provider business mailing address

624 S WOLFE ST
BALTIMORE MD
21231-3034
US

V. Phone/Fax

Practice location:
  • Phone: 240-715-7991
  • Fax:
Mailing address:
  • Phone: 240-715-7991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC14418
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License NumberATC367
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: