Provider Demographics
NPI:1629854286
Name:MIKKILA, CARLY (LPC-IT)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:MIKKILA
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6808 UNIVERSITY AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-2779
Mailing Address - Country:US
Mailing Address - Phone:847-331-0463
Mailing Address - Fax:
Practice Address - Street 1:S73W16485 JANESVILLE RD # 202
Practice Address - Street 2:
Practice Address - City:MUSKEGO
Practice Address - State:WI
Practice Address - Zip Code:53150-8960
Practice Address - Country:US
Practice Address - Phone:920-395-9857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health