Provider Demographics
NPI:1972080018
Name:FLEEGLE, MIKALA SOROKA
Entity Type:Individual
Prefix:
First Name:MIKALA
Middle Name:SOROKA
Last Name:FLEEGLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3750 S RIVER PKWY APT 227
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4746
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14475 SW BARROWS RD
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97007-6103
Practice Address - Country:US
Practice Address - Phone:503-376-6850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-22
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSP-2352235Z00000X
OR16877235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist