Provider Demographics
NPI:1194457689
Name:WOOD, MIKAYLA (MA61329598)
Entity Type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:
Last Name:WOOD
Suffix:
Gender:F
Credentials:MA61329598
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 BASIN ST SW
Mailing Address - Street 2:
Mailing Address - City:EPHRATA
Mailing Address - State:WA
Mailing Address - Zip Code:98823-2135
Mailing Address - Country:US
Mailing Address - Phone:509-754-2461
Mailing Address - Fax:509-754-2462
Practice Address - Street 1:1519 BASIN ST SW
Practice Address - Street 2:
Practice Address - City:EPHRATA
Practice Address - State:WA
Practice Address - Zip Code:98823-2135
Practice Address - Country:US
Practice Address - Phone:509-754-2461
Practice Address - Fax:509-754-2462
Is Sole Proprietor?:No
Enumeration Date:2022-06-24
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61329598225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist