Provider Demographics
NPI:1922407485
Name:KULAWIK, MITCHELL WADE (BS, CADC)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:WADE
Last Name:KULAWIK
Suffix:
Gender:M
Credentials:BS, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 5TH ST STE 520
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51101-1506
Mailing Address - Country:US
Mailing Address - Phone:402-681-5000
Mailing Address - Fax:712-277-2187
Practice Address - Street 1:505 5TH ST STE 520
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51101-1506
Practice Address - Country:US
Practice Address - Phone:402-681-5000
Practice Address - Fax:712-277-2187
Is Sole Proprietor?:No
Enumeration Date:2014-08-20
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
IA1374101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1922407485Medicaid