Basic Information
| Provider Information | |||||||||
| NPI: | 1689688087 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIKITA | ||||||||
| FirstName: | DEBORAH | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6802 TANGLEWOOD DRIVE | ||||||||
| Address2: | |||||||||
| City: | BOARDMAN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306299893 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3679 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | HERMITAGE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 161483411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7249820414 | ||||||||
| FaxNumber: | 7249824407 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 04/25/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PS8073L | PA | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 0016126440004 | 05 | PA | MEDICAID | 000557345 | 01 | PA | HIGHMARK BCBS | OTHER |