MEDICARE: MRS. KRISTEN LYNNE MIKE M.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TS0200X	School Psychologist		AZ

General Provider Information

NPI Number	:	1548277304
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KRISTEN LYNNE MIKE M.A.

Provider Business Mailing Address
First Line	:	3013 S 101ST LN
Second Line	:
City	:	TOLLESON
State	:	AZ
Zip	:	85353-8338
Country	:	US
Telephone Number	:	623-215-2627
Fax Number	:

Provider Business Practice Location Address
First Line	:	3013 S 101ST LN
Second Line	:
City	:	TOLLESON
State	:	AZ
Zip	:	85353-8338
Country	:	US
Telephone Number	:	623-215-2627
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2006
Last Update Date	:	07/25/2007

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