Provider Demographics
NPI:1275097412
Name:SIMCOX, MIKAELA MICHELE
Entity Type:Individual
Prefix:
First Name:MIKAELA
Middle Name:MICHELE
Last Name:SIMCOX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIKAELA
Other - Middle Name:MICHELE
Other - Last Name:SIMCOX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2231 ANDOVER CIR
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34683-1583
Mailing Address - Country:US
Mailing Address - Phone:727-326-4697
Mailing Address - Fax:
Practice Address - Street 1:2231 ANDOVER CIR
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34683-1583
Practice Address - Country:US
Practice Address - Phone:727-326-4697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician