Provider Demographics
NPI:1952680829
Name:MIKOLIC, KAREN M (PHD)
Entity Type:Individual
Prefix:DR
First Name:KAREN
Middle Name:M
Last Name:MIKOLIC
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 721034
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92172-1034
Mailing Address - Country:US
Mailing Address - Phone:858-221-6311
Mailing Address - Fax:888-388-2142
Practice Address - Street 1:4660 LA JOLLA VILLAGE DR STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-4604
Practice Address - Country:US
Practice Address - Phone:858-221-6311
Practice Address - Fax:888-388-2142
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-10
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPSY1000723103T00000X
FLPY8438103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLN/AMedicaid
FLPY8438OtherMEDICAL LICENSE
FLN/AMedicaid