Healthcare Provider Details

I. General information

NPI: 1356082937
Provider Name (Legal Business Name): MIKIKO THELWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2022
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 AMERICAN AVE
KING OF PRUSSIA PA
19406-4023
US

IV. Provider business mailing address

680 AMERICAN AVE
KING OF PRUSSIA PA
19406-4023
US

V. Phone/Fax

Practice location:
  • Phone: 833-351-8255
  • Fax:
Mailing address:
  • Phone: 833-351-8255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD484866
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: