Basic Information
| Provider Information | |||||||||
| NPI: | 1932452414 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIKLOS | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | PATRICK | ||||||||
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| Credential: | L.M.S.W. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 408 JIPSON ST | ||||||||
| Address2: | |||||||||
| City: | BLISSFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492281349 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 257 S MAIN ST STE 2 | ||||||||
| Address2: | |||||||||
| City: | ONSTED | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492659682 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172254668 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2012 | ||||||||
| LastUpdateDate: | 11/05/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | I.1101150-SUPV | OH | N | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | 6801094057 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.