Provider Demographics
NPI:1285009175
Name:MICEK, CAROLYN M (CA)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:M
Last Name:MICEK
Suffix:
Gender:F
Credentials:CA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 HILL ST STE 270
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-3572
Mailing Address - Country:US
Mailing Address - Phone:608-445-6578
Mailing Address - Fax:
Practice Address - Street 1:715 HILL ST STE 270
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-3572
Practice Address - Country:US
Practice Address - Phone:608-445-6578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-03
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI876-55171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist