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General NPI Number Information
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NPI Number | 1043578123
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Entity Type | Individual
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Provider Name | WALTER J MICKULICK M.A., MPA
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Gender | Male
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Dates
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Enumeration Date | 04/26/2012
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Last Update Date | 04/26/2012
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Provider Practice Location Address
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Address Line | 5600 BRAINERD RD STE B42
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City | CHATTANOOGA
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State | TN
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Zip | 37411-5356
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Country | US
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Telephone | 423-605-1855
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Fax | 423-296-6515
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Provider Business Mailing Address
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Address Line | 5600 BRAINERD RD STE B42
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City | CHATTANOOGA
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State | TN
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Zip | 37411-5356
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Country | US
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Telephone | 423-605-1855
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Fax | 423-296-6515
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YS0200X
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Taxonomy Name | School Counselor
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License Number | 7147485
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 7137531
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License Number State | TN
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Taxonomy #3
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Taxonomy Code | 103TF0200X
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Taxonomy Name | Forensic Psychologist
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License Number | 7696871
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License Number State | TN
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Taxonomy #4
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Taxonomy Code | 103TS0200X
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Taxonomy Name | School Psychologist
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License Number | 7147485
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License Number State | TN
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