Provider Demographics
NPI:1043578123
Name:MICKULICK, WALTER J (MA, MPA)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:J
Last Name:MICKULICK
Suffix:
Gender:M
Credentials:MA, MPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5600 BRAINERD RD STE B42
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37411-5356
Mailing Address - Country:US
Mailing Address - Phone:423-605-1855
Mailing Address - Fax:423-296-6515
Practice Address - Street 1:5600 BRAINERD RD STE B42
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37411-5356
Practice Address - Country:US
Practice Address - Phone:423-605-1855
Practice Address - Fax:423-296-6515
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-26
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7147485101YS0200X, 103TS0200X
TN7137531103TC0700X
TN7696871103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool