Provider Demographics
NPI:1588635528
Name:MIKITIN, BARBARA I
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:I
Last Name:MIKITIN
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 1:1045 BREEZEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CANONSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15317-8557
Mailing Address - Country:US
Mailing Address - Phone:724-745-5655
Mailing Address - Fax:
Practice Address - Street 1:1045 BREEZEWOOD DR
Practice Address - Street 2:
Practice Address - City:CANONSBURG
Practice Address - State:PA
Practice Address - Zip Code:15317-8557
Practice Address - Country:US
Practice Address - Phone:724-344-9724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-28
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS003456L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100949442Medicaid