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General NPI Number Information
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NPI Number | 1164180683
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Entity Type | Organization
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Legal Business Name | MIKALA L. SACCOMAN, PHD, LLC
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Dates
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Enumeration Date | 12/01/2021
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Last Update Date | 12/01/2021
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Provider Practice Location Address
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Address Line | 497 SW CENTURY DR STE 104
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City | BEND
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State | OR
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Zip | 97702-1167
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Country | US
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Telephone | 541-678-5174
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Fax | 541-678-5017
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Provider Business Mailing Address
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Address Line | 497 SW CENTURY DR STE 104
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City | BEND
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State | OR
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Zip | 97702-1167
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Country | US
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Telephone | 541-678-5174
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Fax | 541-678-5017
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Authorized Official
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Title or Position | OWNER
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Name | DR. MIKALA L SACCOMAN
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Credential | PHD
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Telephone | 541-678-5174
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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