Provider Demographics
NPI:1205540846
Name:SMITH, MIKAELA JANE
Entity type:Individual
Prefix:
First Name:MIKAELA
Middle Name:JANE
Last Name:SMITH
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 1:5647 BEAR STONE RUN
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-5032
Mailing Address - Country:US
Mailing Address - Phone:407-866-9028
Mailing Address - Fax:
Practice Address - Street 1:1701 PARK CENTER DR STE 202
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-6235
Practice Address - Country:US
Practice Address - Phone:407-286-2021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-22-229080106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician