Healthcare Provider Details

I. General information

NPI: 1295663490
Provider Name (Legal Business Name): MICAH KOINYAN MASSAQUOI JR. LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1964 HOWELL BRANCH RD STE 106
WINTER PARK FL
32792-1042
US

IV. Provider business mailing address

1964 HOWELL BRANCH RD STE 106
WINTER PARK FL
32792-1042
US

V. Phone/Fax

Practice location:
  • Phone: 407-459-4117
  • Fax:
Mailing address:
  • Phone: 407-459-4117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number27328
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: