Healthcare Provider Details

I. General information

NPI: 1285666362
Provider Name (Legal Business Name): GARY W MIJAL LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 01/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7617 MINERAL POINT RD STE 300
MADISON WI
53717-1623
US

IV. Provider business mailing address

7617 MINERAL POINT RD STE 300
MADISON WI
53717-1623
US

V. Phone/Fax

Practice location:
  • Phone: 608-833-9290
  • Fax: 608-833-9691
Mailing address:
  • Phone: 608-833-9290
  • Fax: 608-833-9691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number674-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: