MEDICARE: MIKAELA MICHELE SERGENT MS, BCBA, LBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	7401002674	MI

General Provider Information

NPI Number	:	1609459171
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIKAELA MICHELE SERGENT MS, BCBA, LBA

Provider Business Mailing Address
First Line	:	1615 WHITE ST
Second Line	:
City	:	PORT HURON
State	:	MI
Zip	:	48060-5639
Country	:	US
Telephone Number	:	810-937-7048
Fax Number	:

Provider Business Practice Location Address
First Line	:	1159 S CARNEY DR
Second Line	:
City	:	SAINT CLAIR
State	:	MI
Zip	:	48079-5569
Country	:	US
Telephone Number	:	810-937-7048
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/03/2021
Last Update Date	:	01/30/2025

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