Provider Demographics
NPI:1063120020
Name:MIKKADESH MENTAL HEALTHCARE LLC
Entity type:Organization
Organization Name:MIKKADESH MENTAL HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:ABEH
Authorized Official - Last Name:FORCHU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-649-7584
Mailing Address - Street 1:12923 EMERALD RIDGE BLVD E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-8403
Mailing Address - Country:US
Mailing Address - Phone:801-649-7584
Mailing Address - Fax:
Practice Address - Street 1:12923 EMERALD RIDGE BLVD E
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-8403
Practice Address - Country:US
Practice Address - Phone:801-649-7584
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-09
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty