Provider Demographics
NPI:1134194467
Name:MIKELAIT, ERIC (LMSW)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:MIKELAIT
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3008 S WOODDALE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-3767
Mailing Address - Country:US
Mailing Address - Phone:517-740-6239
Mailing Address - Fax:517-740-6239
Practice Address - Street 1:915 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-1850
Practice Address - Country:US
Practice Address - Phone:517-740-6239
Practice Address - Fax:517-740-6239
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD058421041C0700X
MI68010340361041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1134194467Medicaid
MD698800800Medicaid
MDHE02B772Medicare PIN