Provider Demographics
NPI:1396014759
Name:SACCOMAN, MIKALA (PHD)
Entity Type:Individual
Prefix:
First Name:MIKALA
Middle Name:
Last Name:SACCOMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:497 SW CENTURY DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1167
Mailing Address - Country:US
Mailing Address - Phone:541-678-5174
Mailing Address - Fax:
Practice Address - Street 1:497 SW CENTURY DR
Practice Address - Street 2:STE 104
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1167
Practice Address - Country:US
Practice Address - Phone:541-678-5174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-14
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500647410Medicaid
ORR166086OtherMEDICARE PTAN