Provider Demographics
NPI:1194816512
Name:MIKESELL, JAMES W (PHD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:W
Last Name:MIKESELL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4465 E GENESEE ST # 303
Mailing Address - Street 2:
Mailing Address - City:DE WITT
Mailing Address - State:NY
Mailing Address - Zip Code:13214-2229
Mailing Address - Country:US
Mailing Address - Phone:315-449-0117
Mailing Address - Fax:315-449-9623
Practice Address - Street 1:7000 E GENESEE ST BLDG C
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066
Practice Address - Country:US
Practice Address - Phone:315-449-0117
Practice Address - Fax:315-449-9623
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103G00000X
NY010649103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY018238858Medicaid