Provider Demographics
NPI:1053808006
Name:MICKUNAS, MARISA CATHERINE (MS CRC)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:CATHERINE
Last Name:MICKUNAS
Suffix:
Gender:F
Credentials:MS CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1612 31ST ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50311-2810
Mailing Address - Country:US
Mailing Address - Phone:515-402-3799
Mailing Address - Fax:515-243-2760
Practice Address - Street 1:1301 CENTER ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-1004
Practice Address - Country:US
Practice Address - Phone:515-243-2760
Practice Address - Fax:515-243-2760
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-16
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA090226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty