Provider Demographics
NPI:1568245124
Name:STOVALL, MIKAYLA RENEE
Entity type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:RENEE
Last Name:STOVALL
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 1:208 KING ST
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:SC
Mailing Address - Zip Code:29020-4720
Mailing Address - Country:US
Mailing Address - Phone:803-432-6902
Mailing Address - Fax:
Practice Address - Street 1:1202 TOWN PARK LN STE 300
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3477
Practice Address - Country:US
Practice Address - Phone:706-210-8855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-17
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC010161101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional