=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457437212
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN R MICHALOWSKI LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2006
-----------------------------------------------------
Last Update Date | 08/15/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9 S MILL AVE APT 3
-----------------------------------------------------
City | RIDGWAY
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15853-1043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-594-6829
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24 METOXET ST
-----------------------------------------------------
City | RIDGWAY
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15853-1919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-903-0010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | CW012585
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------