Healthcare Provider Details

I. General information

NPI: 1366137408
Provider Name (Legal Business Name): MIKAYLA CAMPBELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2023
Last Update Date: 03/27/2025
Certification Date: 03/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3880 CATALINA ST
TITUSVILLE FL
32796-2211
US

IV. Provider business mailing address

3601 LIONEL RD
MIMS FL
32754-5306
US

V. Phone/Fax

Practice location:
  • Phone: 321-346-8450
  • Fax:
Mailing address:
  • Phone: 321-747-7277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-271509
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: