Provider Demographics
NPI:1306692702
Name:ABRAHA, MILENA (LAC)
Entity type:Individual
Prefix:
First Name:MILENA
Middle Name:
Last Name:ABRAHA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:MILENA
Other - Middle Name:
Other - Last Name:ANDEBRHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5851 S 23RD WAY
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85040-3499
Mailing Address - Country:US
Mailing Address - Phone:602-380-4336
Mailing Address - Fax:
Practice Address - Street 1:5851 S 23RD WAY
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85040-3499
Practice Address - Country:US
Practice Address - Phone:602-380-4336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-25
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-21379101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health