1922166156 NPI number — MRS. MARILYN RUTH MIKKELSEN LCSW

Table of content: MRS. MARILYN RUTH MIKKELSEN LCSW (NPI 1922166156)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922166156 NPI number — MRS. MARILYN RUTH MIKKELSEN LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIKKELSEN
Provider First Name:
MARILYN
Provider Middle Name:
RUTH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SERVICES
Provider Other First Name:
AGAPE
Provider Other Middle Name:
COUNSELING
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1922166156
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3349 N UNIVERSITY DR
Provider Second Line Business Mailing Address:
SUITE 4
Provider Business Mailing Address City Name:
HOLLYWOOD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33024-9000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-649-0057
Provider Business Mailing Address Fax Number:
954-578-5862

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3349 N UNIVERSITY DR
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
HOLLYWOOD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33024-9000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-649-0057
Provider Business Practice Location Address Fax Number:
954-578-5862
Provider Enumeration Date:
12/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  SW4842 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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