Provider Demographics
NPI:1104455799
Name:MIKITA, ANDREW WILLIAM (LPC)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:WILLIAM
Last Name:MIKITA
Suffix:
Gender:M
Credentials:LPC
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 9694
Mailing Address - Street 2:
Mailing Address - City:BRECKENRIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80424-9016
Mailing Address - Country:US
Mailing Address - Phone:970-333-9622
Mailing Address - Fax:
Practice Address - Street 1:374 LOCALS LANE
Practice Address - Street 2:
Practice Address - City:BRECKENRIDGE
Practice Address - State:CO
Practice Address - Zip Code:80424-8042
Practice Address - Country:US
Practice Address - Phone:970-333-9622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-06
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6014101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional