Healthcare Provider Details

I. General information

NPI: 1982389367
Provider Name (Legal Business Name): MICAH ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2023
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3312 S PEORIA AVE
TULSA OK
74105-2029
US

IV. Provider business mailing address

1200 CROSSWINDS LNDG
FORT WALTON BEACH FL
32547-1174
US

V. Phone/Fax

Practice location:
  • Phone: 918-400-0089
  • Fax:
Mailing address:
  • Phone: 850-226-8279
  • Fax: 850-226-8326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSZ11334
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: