Provider Demographics
NPI:1336261718
Name:LEGAKO, MIKALA ANNE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MIKALA
Middle Name:ANNE
Last Name:LEGAKO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:83 BAILEY DR
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-2913
Mailing Address - Country:US
Mailing Address - Phone:678-314-7469
Mailing Address - Fax:
Practice Address - Street 1:83 BAILEY DR
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-2913
Practice Address - Country:US
Practice Address - Phone:678-314-7469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2020-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002428103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000895617BMedicaid
GA002428OtherPSYCHOLOGY LICENSE