Provider Demographics
NPI:1649660226
Name:MICKETTI, GERALD (LLPC)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:
Last Name:MICKETTI
Suffix:
Gender:M
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W 11TH ST STE 111
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-3288
Mailing Address - Country:US
Mailing Address - Phone:231-499-8290
Mailing Address - Fax:
Practice Address - Street 1:1200 W. 11TH STREET
Practice Address - Street 2:SUITE 111
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-3288
Practice Address - Country:US
Practice Address - Phone:231-499-8290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-03
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012457101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional