Provider Demographics
NPI:1154094241
Name:MIRTIL, LAIKA
Entity Type:Individual
Prefix:
First Name:LAIKA
Middle Name:
Last Name:MIRTIL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAIKA
Other - Middle Name:JEAN
Other - Last Name:MAURICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:540 GLENN GEE RD APT 6205
Mailing Address - Street 2:
Mailing Address - City:PENDERGRASS
Mailing Address - State:GA
Mailing Address - Zip Code:30567-4728
Mailing Address - Country:US
Mailing Address - Phone:812-850-0289
Mailing Address - Fax:
Practice Address - Street 1:540 GLENN GEE RD APT 6205
Practice Address - Street 2:
Practice Address - City:PENDERGRASS
Practice Address - State:GA
Practice Address - Zip Code:30567-4728
Practice Address - Country:US
Practice Address - Phone:812-850-0289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-26
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18-61416106S00000X
GA1-23-67979103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician