Provider Demographics
NPI:1962498584
Name:PAUL, MIKI (PHD)
Entity Type:Individual
Prefix:DR
First Name:MIKI
Middle Name:
Last Name:PAUL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 SOLANO SQ STE 188
Mailing Address - Street 2:
Mailing Address - City:BENICIA
Mailing Address - State:CA
Mailing Address - Zip Code:94510-2712
Mailing Address - Country:US
Mailing Address - Phone:707-771-8080
Mailing Address - Fax:
Practice Address - Street 1:6130 N LA CHOLLA BLVD
Practice Address - Street 2:STE 100
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85741-3589
Practice Address - Country:US
Practice Address - Phone:520-882-1991
Practice Address - Fax:520-742-5655
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY29547103TC0700X
AZ1501103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZPHD 1501Medicare ID - Type Unspecified