Healthcare Provider Details

I. General information

NPI: 1720637507
Provider Name (Legal Business Name): MIKAYLA T PHAN LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2019
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4505 MAYBELLE TRL
KISSIMMEE FL
34746-3335
US

IV. Provider business mailing address

4505 MAYBELLE TRL
KISSIMMEE FL
34746-3335
US

V. Phone/Fax

Practice location:
  • Phone: 608-733-1441
  • Fax:
Mailing address:
  • Phone: 608-733-1441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number5204
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1403-124
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: