Provider Demographics
NPI:1275982639
Name:MICKULAS, PHILIP MICHAEL (LCSW)
Entity Type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:MICHAEL
Last Name:MICKULAS
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 1:115 HOLLY AVE
Mailing Address - Street 2:
Mailing Address - City:HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11550-5209
Mailing Address - Country:US
Mailing Address - Phone:516-456-1189
Mailing Address - Fax:
Practice Address - Street 1:115 HOLLY AVE
Practice Address - Street 2:
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-5209
Practice Address - Country:US
Practice Address - Phone:516-456-1189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPR014494-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical