Provider Demographics
NPI:1942653340
Name:MIRKIN, LEORA
Entity Type:Individual
Prefix:
First Name:LEORA
Middle Name:
Last Name:MIRKIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2614 RAVENSWOOD RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-4053
Mailing Address - Country:US
Mailing Address - Phone:608-406-3860
Mailing Address - Fax:608-403-4257
Practice Address - Street 1:2614 RAVENSWOOD RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-4053
Practice Address - Country:US
Practice Address - Phone:608-406-3860
Practice Address - Fax:608-403-4257
Is Sole Proprietor?:No
Enumeration Date:2016-07-20
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical