Provider Demographics
NPI:1538618327
Name:ANDERSON, MIKELLA (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:MIKELLA
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:MIKELLA
Other - Middle Name:
Other - Last Name:BRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 450
Mailing Address - Street 2:
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:179 STATION PLACE SUITE 100
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526
Practice Address - Country:US
Practice Address - Phone:304-760-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-22
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1838225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist