Healthcare Provider Details

I. General information

NPI: 1871089417
Provider Name (Legal Business Name): MIKAELA BERCOW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2018
Last Update Date: 07/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

187 E WILBUR RD STE 6
THOUSAND OAKS CA
91360-7928
US

IV. Provider business mailing address

187 E WILBUR RD STE 6
THOUSAND OAKS CA
91360-7928
US

V. Phone/Fax

Practice location:
  • Phone: 805-230-3701
  • Fax:
Mailing address:
  • Phone: 805-230-3701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: