Provider Demographics
NPI:1669839288
Name:MIKESELL-BOBO, MIA
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:
Last Name:MIKESELL-BOBO
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 1:21500 SOUTHERN CHARM DR
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34637-7628
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4144 N ARMENIA AVE
Practice Address - Street 2:STE. 350
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6400
Practice Address - Country:US
Practice Address - Phone:813-482-6360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-27
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH 13410101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health