Healthcare Provider Details

I. General information

NPI: 1033024906
Provider Name (Legal Business Name): MIKALAH GOLDWIRE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 LEEFIELD DR
SAVANNAH GA
31419-3510
US

IV. Provider business mailing address

120 LEEFIELD DR
SAVANNAH GA
31419-3510
US

V. Phone/Fax

Practice location:
  • Phone: 912-604-7579
  • Fax: 912-604-7579
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-389532
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: