Provider Demographics
NPI:1104538800
Name:GOEPFRICH, MIKAYLA NICOLE
Entity type:Individual
Prefix:MRS
First Name:MIKAYLA
Middle Name:NICOLE
Last Name:GOEPFRICH
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:MIKAYLA
Other - Middle Name:NICOLE
Other - Last Name:NOLT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2197 GRASMERE DR
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32703-7669
Mailing Address - Country:US
Mailing Address - Phone:717-475-3155
Mailing Address - Fax:
Practice Address - Street 1:1000 COLOR PL # 101
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32703-7717
Practice Address - Country:US
Practice Address - Phone:888-754-0398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-14
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician