=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497624654
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIKAYLA ESTRADA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2025
-----------------------------------------------------
Last Update Date | 11/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 595 W MAIN ST
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13601-1335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-782-1777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 482 BLACK RIVER PKWY
-----------------------------------------------------
City | WATERTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13601-2416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-788-1530
-----------------------------------------------------
Fax | 315-782-1777
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | P138697
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------