Provider Demographics
NPI:1902413941
Name:MIKA, STACEY L (MS, BCBA)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:L
Last Name:MIKA
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 MAPLE TER
Mailing Address - Street 2:
Mailing Address - City:NESQUEHONING
Mailing Address - State:PA
Mailing Address - Zip Code:18240-2125
Mailing Address - Country:US
Mailing Address - Phone:570-952-4066
Mailing Address - Fax:
Practice Address - Street 1:9 BANKS AVE
Practice Address - Street 2:
Practice Address - City:MCADOO
Practice Address - State:PA
Practice Address - Zip Code:18237-2508
Practice Address - Country:US
Practice Address - Phone:570-802-3099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA12044424103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst