Provider Demographics
NPI:1154742807
Name:MCCOY, MIKAELIAN
Entity type:Individual
Prefix:
First Name:MIKAELIAN
Middle Name:
Last Name:MCCOY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1224 RAINY SKY AVE
Mailing Address - Street 2:
Mailing Address - City:N LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89030-3710
Mailing Address - Country:US
Mailing Address - Phone:702-927-4075
Mailing Address - Fax:
Practice Address - Street 1:1224 RAINY SKY AVE
Practice Address - Street 2:
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-3710
Practice Address - Country:US
Practice Address - Phone:702-927-4075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-25
Last Update Date:2013-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1404064724103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst