Provider Demographics
NPI:1790841179
Name:MIKALSON, MARY E (MSSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:MIKALSON
Suffix:
Gender:F
Credentials:MSSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 W MAIN ST
Mailing Address - Street 2:SUIT 3
Mailing Address - City:SUN PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53590-2849
Mailing Address - Country:US
Mailing Address - Phone:608-825-6663
Mailing Address - Fax:608-825-6946
Practice Address - Street 1:705 W MAIN ST
Practice Address - Street 2:SUIT 3
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-2849
Practice Address - Country:US
Practice Address - Phone:608-825-6663
Practice Address - Fax:608-825-6946
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2822-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39255200Medicaid