Provider Demographics
NPI:1770649790
Name:MICKOLAJCZYK, VIRGINIA
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:MICKOLAJCZYK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VIRGINIA
Other - Middle Name:
Other - Last Name:CONNELLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:0-14 WHITEHALL ST
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-2913
Mailing Address - Country:US
Mailing Address - Phone:201-791-7669
Mailing Address - Fax:201-791-8223
Practice Address - Street 1:4-21 BANTA PL # A
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-3067
Practice Address - Country:US
Practice Address - Phone:201-794-9000
Practice Address - Fax:201-794-9001
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJSC0057511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ200590953OtherEIN
NJ200590953OtherEIN