Provider Demographics
NPI:1518682210
Name:FLOURNOY, MYKAELAN
Entity Type:Individual
Prefix:
First Name:MYKAELAN
Middle Name:
Last Name:FLOURNOY
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 1:8802 N SAM HOUSTON PKWY E APT 7206
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77396-5046
Mailing Address - Country:US
Mailing Address - Phone:832-834-8874
Mailing Address - Fax:
Practice Address - Street 1:10023 MAIN ST STE C4
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77025-5252
Practice Address - Country:US
Practice Address - Phone:713-497-5540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-05
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-21-160418106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician