Provider Demographics
NPI:1700412764
Name:SULTANIK, MIA
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:
Last Name:SULTANIK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2251 BAGDAD RD STE 303
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-6522
Mailing Address - Country:US
Mailing Address - Phone:512-970-2338
Mailing Address - Fax:
Practice Address - Street 1:2251 BAGDAD RD STE 303
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-6522
Practice Address - Country:US
Practice Address - Phone:512-970-2338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-20
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX508591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical