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General NPI Number Information
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NPI Number | 1164191698
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Entity Type | Organization
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Legal Business Name | MITKOF BEHAVIORAL HEALTH LLC
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Dates
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Enumeration Date | 09/08/2021
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Last Update Date | 05/05/2022
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Provider Practice Location Address
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Address Line | 403 HAUGEN DRIVE #103
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City | PETERSBURG
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State | AK
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Zip | 99833-0771
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Country | US
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Telephone | 907-650-0222
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Fax | 907-772-3710
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Provider Business Mailing Address
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Address Line | PO BOX 771
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City | PETERSBURG
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State | AK
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Zip | 99833-0771
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Country | US
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Telephone | 907-650-0222
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | KARA B WESEBAUM
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Credential | LCSW
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Telephone | 907-650-0222
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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