Healthcare Provider Details

I. General information

NPI: 1528929866
Provider Name (Legal Business Name): MIKEILA RAE HANSEN
Entity Type: Individual
Gender:
Sole Proprietor: N

Provider Other Name: MIKEILA VAN DYKE

II. Dates (important events)

Enumeration Date: 11/18/2025
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 UPLAND ST
KENAI AK
99611-8026
US

IV. Provider business mailing address

PO BOX 988
KENAI AK
99611-0988
US

V. Phone/Fax

Practice location:
  • Phone: 907-335-7500
  • Fax:
Mailing address:
  • Phone: 907-335-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: