Provider Demographics
NPI:1306994728
Name:MIKULA, JAMES W (MSW)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:W
Last Name:MIKULA
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 LAWNDALE AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-3736
Mailing Address - Country:US
Mailing Address - Phone:616-235-7482
Mailing Address - Fax:
Practice Address - Street 1:800 E BELTLINE AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-5848
Practice Address - Country:US
Practice Address - Phone:616-456-6135
Practice Address - Fax:616-771-9779
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010859991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID16163026Medicare ID - Type Unspecified