Provider Demographics
NPI:1154473213
Name:MIKKELSEN, DENNIS (LCSW)
Entity Type:Individual
Prefix:MR
First Name:DENNIS
Middle Name:
Last Name:MIKKELSEN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 ROLLING HILL RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08809-2617
Mailing Address - Country:US
Mailing Address - Phone:201-725-8022
Mailing Address - Fax:
Practice Address - Street 1:601 BROADWAY
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-3818
Practice Address - Country:US
Practice Address - Phone:201-339-9200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC048091001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0021806Medicaid
NJ0021806Medicaid