Provider Demographics
NPI:1972255792
Name:SOUBIK, MIKAELA GRACE (OTR/L)
Entity type:Individual
Prefix:
First Name:MIKAELA
Middle Name:GRACE
Last Name:SOUBIK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 W NORWEGIAN ST
Mailing Address - Street 2:
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901-2212
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1234 W NORWEGIAN ST
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-2212
Practice Address - Country:US
Practice Address - Phone:570-516-6490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-23
Last Update Date:2022-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC018136225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty