Provider Demographics
NPI:1629437108
Name:WRUK-WILKIE, MIKAYLA CINTHIA
Entity Type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:CINTHIA
Last Name:WRUK-WILKIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIKAYLA
Other - Middle Name:CINTHIA
Other - Last Name:WRUK-NORMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3587 HEATHROW WAY
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4004
Mailing Address - Country:US
Mailing Address - Phone:559-905-6199
Mailing Address - Fax:
Practice Address - Street 1:13850 SE AUTUMN RIDGE TER
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97267-2150
Practice Address - Country:US
Practice Address - Phone:503-974-9250
Practice Address - Fax:503-974-9586
Is Sole Proprietor?:No
Enumeration Date:2016-02-12
Last Update Date:2019-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health