Provider Demographics
NPI:1063078384
Name:HANSON, MIKALA RAE (PSYD; BCBA-D)
Entity type:Individual
Prefix:MISS
First Name:MIKALA
Middle Name:RAE
Last Name:HANSON
Suffix:
Gender:F
Credentials:PSYD; BCBA-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 ABERDEEN WAY
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-9559
Mailing Address - Country:US
Mailing Address - Phone:813-471-8721
Mailing Address - Fax:
Practice Address - Street 1:230 S NOLEN DR BLDG 3
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-8078
Practice Address - Country:US
Practice Address - Phone:817-402-8250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-13
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-17-25337103K00000X
MD06416103TC0700X
TX38644103TC0700X
390200000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program