Provider Demographics
NPI:1841558764
Name:MIKOLAZYK, CORY
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:
Last Name:MIKOLAZYK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1170 WILSON RD
Mailing Address - Street 2:UNIT # 35
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02720-4600
Mailing Address - Country:US
Mailing Address - Phone:508-558-6120
Mailing Address - Fax:
Practice Address - Street 1:1170 WILSON RD
Practice Address - Street 2:UNIT # 35
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-4600
Practice Address - Country:US
Practice Address - Phone:508-558-6120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-28
Last Update Date:2012-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health