Provider Demographics
NPI:1497776587
Name:MICKLER, TANYA J (PHD)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:J
Last Name:MICKLER
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 1:4965 SW 91ST TER
Mailing Address - Street 2:STE A
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-8149
Mailing Address - Country:US
Mailing Address - Phone:352-337-0551
Mailing Address - Fax:352-374-2166
Practice Address - Street 1:4965 SW 91ST TER
Practice Address - Street 2:STE A
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-8149
Practice Address - Country:US
Practice Address - Phone:352-337-0551
Practice Address - Fax:352-374-2166
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5842103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical