Provider Demographics
NPI:1376556886
Name:MIKA, VIRGINIA HELENE (MSOTR/L)
Entity Type:Individual
Prefix:MRS
First Name:VIRGINIA
Middle Name:HELENE
Last Name:MIKA
Suffix:
Gender:F
Credentials:MSOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1037
Mailing Address - Street 2:
Mailing Address - City:PINEDALE
Mailing Address - State:WY
Mailing Address - Zip Code:82941-1037
Mailing Address - Country:US
Mailing Address - Phone:307-367-6236
Mailing Address - Fax:307-367-3332
Practice Address - Street 1:317 N FALER AVE
Practice Address - Street 2:
Practice Address - City:PINEDALE
Practice Address - State:WY
Practice Address - Zip Code:82941
Practice Address - Country:US
Practice Address - Phone:307-367-6236
Practice Address - Fax:307-367-3332
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYOTR532225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY119287600Medicaid
WY312278OtherBLUE CROSS BLUE SHIELD
WY9761Medicare ID - Type Unspecified