Provider Demographics
NPI:1659988830
Name:ALTMAN, MIKAYLA CHEYENNE
Entity Type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:CHEYENNE
Last Name:ALTMAN
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 1:244 BRANCHWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:KINGS MOUNTAIN
Mailing Address - State:NC
Mailing Address - Zip Code:28086-7787
Mailing Address - Country:US
Mailing Address - Phone:704-215-2351
Mailing Address - Fax:704-215-2351
Practice Address - Street 1:2675 COURT DR
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-1478
Practice Address - Country:US
Practice Address - Phone:704-824-4999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC34182511106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician