Provider Demographics
NPI:1548980493
Name:GOLDMAN, MIKAYLA LYNN
Entity type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:LYNN
Last Name:GOLDMAN
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 1:23679 ARBORETUM WAY
Mailing Address - Street 2:UNIT 1401
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563
Mailing Address - Country:US
Mailing Address - Phone:951-595-3303
Mailing Address - Fax:
Practice Address - Street 1:25285 MADISON AVE STE 101
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-8955
Practice Address - Country:US
Practice Address - Phone:951-397-0086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-31
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician