Provider Demographics
NPI:1669148409
Name:CAMACHO, MIKAYLA ALEXANDRA (BCBA)
Entity type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:ALEXANDRA
Last Name:CAMACHO
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1188 N 230 W
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2255
Mailing Address - Country:US
Mailing Address - Phone:678-637-5589
Mailing Address - Fax:
Practice Address - Street 1:429 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-5207
Practice Address - Country:US
Practice Address - Phone:801-683-1062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-20
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-24-352746106S00000X
UT1-24-75956103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC236Medicaid
568946544OtherBCBS
5874OtherHEALTH PARTNERS