Individual
MIKALA SACCOMAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PHD
Contact information
Practice address
497 SW CENTURY DR, STE 104, BEND, OR 97702-1167
(541) 678-5174
Mailing address
497 SW CENTURY DR, BEND, OR 97702-1167
(541) 678-5174
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
500647410
—
OR
01
—
R166086
MEDICARE PTAN
OR
Enumeration date
12/14/2011
Last updated
01/19/2016
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