Provider Demographics
NPI:1285199505
Name:JUAN, MYKA JARMANE DIAZ
Entity type:Individual
Prefix:
First Name:MYKA JARMANE
Middle Name:DIAZ
Last Name:JUAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 COLLEGE PARK DR APT 915
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77384-4377
Mailing Address - Country:US
Mailing Address - Phone:949-400-4383
Mailing Address - Fax:
Practice Address - Street 1:23775 KINGWOOD PLACE DR
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339-3817
Practice Address - Country:US
Practice Address - Phone:281-318-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-31
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1224459225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist