Provider Demographics
NPI:1205490695
Name:MIKITA, ABBY ROSE (LLBSW, QIDP)
Entity type:Individual
Prefix:
First Name:ABBY
Middle Name:ROSE
Last Name:MIKITA
Suffix:
Gender:F
Credentials:LLBSW, QIDP
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 141004
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49514-1004
Mailing Address - Country:US
Mailing Address - Phone:616-414-1068
Mailing Address - Fax:616-591-5723
Practice Address - Street 1:6654 E FAWN AVE
Practice Address - Street 2:
Practice Address - City:WHITE CLOUD
Practice Address - State:MI
Practice Address - Zip Code:49349-9326
Practice Address - Country:US
Practice Address - Phone:616-414-1068
Practice Address - Fax:616-591-5723
Is Sole Proprietor?:No
Enumeration Date:2019-05-01
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802090070104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker