Provider Demographics
NPI:1467203364
Name:REID, MICKELA LASANIA
Entity Type:Individual
Prefix:
First Name:MICKELA
Middle Name:LASANIA
Last Name:REID
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 1:60 DONNA DR UNIT C2
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06513-1446
Mailing Address - Country:US
Mailing Address - Phone:347-399-3602
Mailing Address - Fax:
Practice Address - Street 1:2666 STATE ST STE A3
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06517-2232
Practice Address - Country:US
Practice Address - Phone:860-544-0356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician