Provider Demographics
NPI:1588339949
Name:LEORA MIRKIN THERAPY LLC
Entity type:Organization
Organization Name:LEORA MIRKIN THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR AND THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:LEORA
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRKIN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:608-406-3860
Mailing Address - Street 1:2614 RAVENSWOOD RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-4053
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2614 RAVENSWOOD RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-4053
Practice Address - Country:US
Practice Address - Phone:608-406-3860
Practice Address - Fax:608-403-4257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-09
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty