Healthcare Provider Details

I. General information

NPI: 1720386337
Provider Name (Legal Business Name): JONATHAN DANIEL MIKULAK L.S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2011
Last Update Date: 03/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3063 FREEPORT RD SUITE B
NATRONA HEIGHTS PA
15065-1967
US

IV. Provider business mailing address

6134 HALLWOOD DR
VERONA PA
15147-2523
US

V. Phone/Fax

Practice location:
  • Phone: 724-766-9238
  • Fax: 724-226-0931
Mailing address:
  • Phone: 412-996-6818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW126542
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: