Provider Demographics
NPI:1689688087
Name:MIKITA, DEBORAH J (MA)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:J
Last Name:MIKITA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6802 TANGLEWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512
Mailing Address - Country:US
Mailing Address - Phone:330-629-9893
Mailing Address - Fax:
Practice Address - Street 1:3679 E STATE ST
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:PA
Practice Address - Zip Code:16148-3411
Practice Address - Country:US
Practice Address - Phone:724-982-0414
Practice Address - Fax:724-982-4407
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS8073L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016126440004Medicaid
PA000557345OtherHIGHMARK BCBS
PA0016126440004Medicaid