Provider Demographics
NPI:1386245694
Name:ALLEN, MIKO RAE (PT, LCSW)
Entity type:Individual
Prefix:
First Name:MIKO
Middle Name:RAE
Last Name:ALLEN
Suffix:
Gender:F
Credentials:PT, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22572 LITTLE JOHN DR
Mailing Address - Street 2:
Mailing Address - City:TWAIN HARTE
Mailing Address - State:CA
Mailing Address - Zip Code:95383-9758
Mailing Address - Country:US
Mailing Address - Phone:805-591-9990
Mailing Address - Fax:209-336-0293
Practice Address - Street 1:175 FAIRVIEW LN
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-4809
Practice Address - Country:US
Practice Address - Phone:805-591-9990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37930167G00000X
CA1176831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No167G00000XNursing Service ProvidersLicensed Psychiatric Technician