Provider Demographics
NPI:1376707463
Name:DAVID G. MIKKOLA PC
Entity Type:Organization
Organization Name:DAVID G. MIKKOLA PC
Other - Org Name:DAVID G. MIKKOLA LMSW PC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:MIKKOLA
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:248-644-3200
Mailing Address - Street 1:30200 TELEGRAPH RD
Mailing Address - Street 2:SUITE 402
Mailing Address - City:BINGHAM FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-4502
Mailing Address - Country:US
Mailing Address - Phone:248-644-3200
Mailing Address - Fax:248-644-3211
Practice Address - Street 1:30200 TELEGRAPH RD
Practice Address - Street 2:SUITE 402
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-4502
Practice Address - Country:US
Practice Address - Phone:248-644-3200
Practice Address - Fax:248-644-3211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-17
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801031411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty