Provider Demographics
NPI:1164180683
Name:MIKALA L. SACCOMAN, PHD, LLC
Entity Type:Organization
Organization Name:MIKALA L. SACCOMAN, PHD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MIKALA
Authorized Official - Middle Name:L
Authorized Official - Last Name:SACCOMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:541-678-5174
Mailing Address - Street 1:497 SW CENTURY DR STE 104
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1167
Mailing Address - Country:US
Mailing Address - Phone:541-678-5174
Mailing Address - Fax:541-678-5017
Practice Address - Street 1:497 SW CENTURY DR STE 104
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1167
Practice Address - Country:US
Practice Address - Phone:541-678-5174
Practice Address - Fax:541-678-5017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-01
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty