Healthcare Provider Details

I. General information

NPI: 1043578123
Provider Name (Legal Business Name): WALTER J MICKULICK M.A., MPA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2012
Last Update Date: 04/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5600 BRAINERD RD STE B42
CHATTANOOGA TN
37411-5356
US

IV. Provider business mailing address

5600 BRAINERD RD STE B42
CHATTANOOGA TN
37411-5356
US

V. Phone/Fax

Practice location:
  • Phone: 423-605-1855
  • Fax: 423-296-6515
Mailing address:
  • Phone: 423-605-1855
  • Fax: 423-296-6515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number7147485
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number7137531
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number7696871
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number7147485
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: