Provider Demographics
NPI:1336398445
Name:MICKLAS, COLLEEN MARY
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MARY
Last Name:MICKLAS
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 1:114 ORCHARD LAKE RD
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-2244
Mailing Address - Country:US
Mailing Address - Phone:248-858-7766
Mailing Address - Fax:248-858-7201
Practice Address - Street 1:130 HAMPTON CIR
Practice Address - Street 2:SUITE 100
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-4195
Practice Address - Country:US
Practice Address - Phone:248-853-0750
Practice Address - Fax:248-853-0792
Is Sole Proprietor?:No
Enumeration Date:2008-09-12
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1883825Medicaid