Provider Demographics
NPI:1164191698
Name:MITKOF BEHAVIORAL HEALTH LLC
Entity Type:Organization
Organization Name:MITKOF BEHAVIORAL HEALTH LLC
Other - Org Name:MITKOF BEHAVIORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KARA
Authorized Official - Middle Name:B
Authorized Official - Last Name:WESEBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:907-650-0222
Mailing Address - Street 1:PO BOX 771
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:AK
Mailing Address - Zip Code:99833-0771
Mailing Address - Country:US
Mailing Address - Phone:907-650-0222
Mailing Address - Fax:
Practice Address - Street 1:403 HAUGEN DRIVE
Practice Address - Street 2:#103
Practice Address - City:PETERSBURG
Practice Address - State:AK
Practice Address - Zip Code:99833-0771
Practice Address - Country:US
Practice Address - Phone:907-650-0222
Practice Address - Fax:907-772-3710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-08
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK99833Medicaid