Provider Demographics
NPI:1386963676
Name:MIKON, BRADLEY LOREN (LLMSW)
Entity type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:LOREN
Last Name:MIKON
Suffix:
Gender:M
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44899 CENTRE CT
Mailing Address - Street 2:SIOTE 102
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-5510
Mailing Address - Country:US
Mailing Address - Phone:586-792-1654
Mailing Address - Fax:586-792-1656
Practice Address - Street 1:44899 CENTRE CT
Practice Address - Street 2:SIOTE 102
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-5510
Practice Address - Country:US
Practice Address - Phone:586-792-1654
Practice Address - Fax:586-792-1656
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-26
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010907501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical