Provider Demographics
NPI:1225786924
Name:COLVIN, MYKALIA
Entity Type:Individual
Prefix:
First Name:MYKALIA
Middle Name:
Last Name:COLVIN
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 1:249 BAYFIELD LOOP
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-8604
Mailing Address - Country:US
Mailing Address - Phone:910-583-2720
Mailing Address - Fax:
Practice Address - Street 1:249 BAYFIELD LOOP
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-8604
Practice Address - Country:US
Practice Address - Phone:910-583-2720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-13
Last Update Date:2022-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC946315552KMedicaid