Provider Demographics
NPI:1285666362
Name:MIJAL, GARY W (LCSW)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:W
Last Name:MIJAL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7617 MINERAL POINT RD
Mailing Address - Street 2:STE 300
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53717-1623
Mailing Address - Country:US
Mailing Address - Phone:608-833-9290
Mailing Address - Fax:608-833-9691
Practice Address - Street 1:7617 MINERAL POINT RD
Practice Address - Street 2:STE 300
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53717-1623
Practice Address - Country:US
Practice Address - Phone:608-833-9290
Practice Address - Fax:608-833-9691
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI674-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI12761OtherDEAN
WI391627035010OtherBLUE CROSS/BLUE SHIELD
WI39518100Medicaid
WI39518100Medicaid