Provider Demographics
NPI:1235600446
Name:RYSHYTYLO, MIKAELA COLLEEN
Entity Type:Individual
Prefix:
First Name:MIKAELA
Middle Name:COLLEEN
Last Name:RYSHYTYLO
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 1:5227 W ADAMS AVE APT 1027
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-4859
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5227 W ADAMS AVE APT 1027
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76502-4859
Practice Address - Country:US
Practice Address - Phone:307-399-4249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician