Provider Demographics
NPI:1386897353
Name:MIKULKA, ROSANNE TERRY (MA)
Entity type:Individual
Prefix:MRS
First Name:ROSANNE
Middle Name:TERRY
Last Name:MIKULKA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MRS
Other - First Name:ROSANNE
Other - Middle Name:THERESA
Other - Last Name:MIKULKA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA
Mailing Address - Street 1:602 VONDERBURG DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5900
Mailing Address - Country:US
Mailing Address - Phone:813-653-1149
Mailing Address - Fax:813-654-6644
Practice Address - Street 1:602 VONDERBURG DR
Practice Address - Street 2:SUITE 201
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5900
Practice Address - Country:US
Practice Address - Phone:813-653-1149
Practice Address - Fax:813-654-6644
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-03
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005253235Z00000X
FLSA14917235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist