Provider Demographics
NPI:1003418815
Name:MIECZKOWSKI, MICHAEL A (MS,CADC CSAT CMAT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:MIECZKOWSKI
Suffix:
Gender:M
Credentials:MS,CADC CSAT CMAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5547 55TH TER
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32967-2473
Mailing Address - Country:US
Mailing Address - Phone:336-403-0635
Mailing Address - Fax:
Practice Address - Street 1:5547 55TH TER
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32967-2473
Practice Address - Country:US
Practice Address - Phone:336-403-0635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA8096101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)