Healthcare Provider Details

I. General information

NPI: 1669148409
Provider Name (Legal Business Name): MIKAYLA ALEXANDRA CAMACHO BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2021
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

429 S MAIN ST
LOGAN UT
84321-5207
US

IV. Provider business mailing address

1188 N 230 W
LOGAN UT
84341-2255
US

V. Phone/Fax

Practice location:
  • Phone: 801-683-1062
  • Fax:
Mailing address:
  • Phone: 678-637-5589
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-24-75956
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-352746
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: