Provider Demographics
NPI:1760140081
Name:DEFORE, MIKAYLA MADISON (LMSW)
Entity Type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:MADISON
Last Name:DEFORE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 SAINT NICHOLAS AVE APT 6G
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10030-1919
Mailing Address - Country:US
Mailing Address - Phone:706-483-6586
Mailing Address - Fax:
Practice Address - Street 1:580 SAINT NICHOLAS AVE APT 6G
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10030-1919
Practice Address - Country:US
Practice Address - Phone:706-483-6586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-03
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY111870104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker