Provider Demographics
NPI:1609239300
Name:MIKULICHEK, COURTNEY (BC-HIS)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:MIKULICHEK
Suffix:
Gender:F
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3385 ROY ORR BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75050-4208
Mailing Address - Country:US
Mailing Address - Phone:469-586-0437
Mailing Address - Fax:
Practice Address - Street 1:14940 FLORENCE TRL
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-4628
Practice Address - Country:US
Practice Address - Phone:612-355-3918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-30
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2756237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist