Provider Demographics
NPI:1841703634
Name:VICTORIA MICHALEK, LLC
Entity type:Organization
Organization Name:VICTORIA MICHALEK, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MICHALEK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:203-648-2886
Mailing Address - Street 1:148 MIDDLE RIVER RD
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06811-4339
Mailing Address - Country:US
Mailing Address - Phone:203-648-2886
Mailing Address - Fax:475-282-3442
Practice Address - Street 1:14 DEPOT PL FL 1
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:CT
Practice Address - Zip Code:06801-2540
Practice Address - Country:US
Practice Address - Phone:475-289-4824
Practice Address - Fax:475-282-3442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-15
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT007931251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD300245896Medicaid