Healthcare Provider Details

I. General information

NPI: 1477159507
Provider Name (Legal Business Name): MIKAELA PITCAN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2020
Last Update Date: 12/15/2023
Certification Date: 12/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HOSPITAL AMERICANO BASE NAVAL DE ROTA APARTADO DE CORRE
FPO AE
11530
US

IV. Provider business mailing address

5502 MARVIN SHIELDS BOULEVARD
GULFPORT MS
39501
US

V. Phone/Fax

Practice location:
  • Phone: 495-682-3305
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number2203
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: