Healthcare Provider Details

I. General information

NPI: 1386245694
Provider Name (Legal Business Name): MIKO RAE ALLEN PT, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2020
Last Update Date: 03/21/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 FAIRVIEW LN
SONORA CA
95370-4809
US

IV. Provider business mailing address

22572 LITTLE JOHN DR
TWAIN HARTE CA
95383-9758
US

V. Phone/Fax

Practice location:
  • Phone: 805-591-9990
  • Fax:
Mailing address:
  • Phone: 805-591-9990
  • Fax: 209-336-0293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number117683
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number37930
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: