Provider Demographics
NPI:1154929941
Name:PACIFICO, MIKA LEY CYRUS (OTR)
Entity type:Individual
Prefix:MRS
First Name:MIKA LEY CYRUS
Middle Name:
Last Name:PACIFICO
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MS
Other - First Name:MIKA LEY CYRUS
Other - Middle Name:
Other - Last Name:VERDIDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOT
Mailing Address - Street 1:1061 HARMON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31314-5641
Mailing Address - Country:US
Mailing Address - Phone:912-435-6965
Mailing Address - Fax:
Practice Address - Street 1:1061 HARMON AVE
Practice Address - Street 2:
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314-5641
Practice Address - Country:US
Practice Address - Phone:912-435-6965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-13
Last Update Date:2024-03-11
Deactivation Date:2022-07-15
Deactivation Code:
Reactivation Date:2023-09-06
Provider Licenses
StateLicense IDTaxonomies
CA21681225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist