Healthcare Provider Details

I. General information

NPI: 1154733855
Provider Name (Legal Business Name): JOSEPH THOMAS MIKULKA LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2014
Last Update Date: 08/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 W 239TH ST
BRONX NY
10463-1205
US

IV. Provider business mailing address

30 W 86TH ST APT 1F
NEW YORK NY
10024-3600
US

V. Phone/Fax

Practice location:
  • Phone: 718-601-2280
  • Fax:
Mailing address:
  • Phone: 646-450-3153
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number084337-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: