Provider Demographics
NPI:1558362285
Name:MIKALAC, CECILIA (MD)
Entity Type:Individual
Prefix:
First Name:CECILIA
Middle Name:
Last Name:MIKALAC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01609-2183
Mailing Address - Country:US
Mailing Address - Phone:508-752-7529
Mailing Address - Fax:
Practice Address - Street 1:57 CEDAR ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01609-2183
Practice Address - Country:US
Practice Address - Phone:508-752-7529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA572802084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIJ08334OtherBLUE CROSS
MA3046770Medicaid
MA3046770Medicaid