Provider Demographics
NPI:1093436925
Name:NICHOLLS, MIKAELA C
Entity Type:Individual
Prefix:
First Name:MIKAELA
Middle Name:C
Last Name:NICHOLLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19800 VILLAGE OFFICE CT STE 104
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1813
Mailing Address - Country:US
Mailing Address - Phone:541-306-3483
Mailing Address - Fax:541-639-8909
Practice Address - Street 1:19800 VILLAGE OFFICE CT STE 104
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1813
Practice Address - Country:US
Practice Address - Phone:541-306-3483
Practice Address - Fax:541-639-8909
Is Sole Proprietor?:No
Enumeration Date:2022-09-08
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORABA-IN-10225094106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician