Provider Demographics
NPI:1679361570
Name:CARPENTER, MIKAELA
Entity type:Individual
Prefix:
First Name:MIKAELA
Middle Name:
Last Name:CARPENTER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2855 E BROWN RD STE 9
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-4215
Mailing Address - Country:US
Mailing Address - Phone:480-997-1220
Mailing Address - Fax:
Practice Address - Street 1:2855 E BROWN RD STE 9
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85213-4215
Practice Address - Country:US
Practice Address - Phone:480-997-1220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-29
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician