Provider Demographics
NPI:1295214260
Name:VONDRA, MIKA J (BACB40127)
Entity Type:Individual
Prefix:
First Name:MIKA
Middle Name:J
Last Name:VONDRA
Suffix:
Gender:F
Credentials:BACB40127
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 W NICHOLS RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60004-1323
Mailing Address - Country:US
Mailing Address - Phone:847-744-9642
Mailing Address - Fax:
Practice Address - Street 1:703 W NICHOLS RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60004-1323
Practice Address - Country:US
Practice Address - Phone:847-744-9642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-10
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILBACB40127106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician