Provider Demographics
NPI:1710741343
Name:MICKLER, DOMINIQUE JALISIA (LCSW)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:JALISIA
Last Name:MICKLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 12TH ST E
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-2120
Mailing Address - Country:US
Mailing Address - Phone:941-920-8436
Mailing Address - Fax:
Practice Address - Street 1:360 CENTRAL AVE STE 1230
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-3865
Practice Address - Country:US
Practice Address - Phone:172-756-5242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-13
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW226411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical