Provider Demographics
NPI:1700407079
Name:MOORE, MIKAYLA (BCABA)
Entity Type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16930 ROBBINS RD STE 120
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-2784
Mailing Address - Country:US
Mailing Address - Phone:616-935-7606
Mailing Address - Fax:
Practice Address - Street 1:16930 ROBBINS RD STE 120
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-2784
Practice Address - Country:US
Practice Address - Phone:616-935-7606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-28
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0-18-9394106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst