Provider Demographics
NPI:1679870505
Name:AWANOHARA, MIKA (PSYD)
Entity type:Individual
Prefix:DR
First Name:MIKA
Middle Name:
Last Name:AWANOHARA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1902 W. DICKERSON ST.
Mailing Address - Street 2:SUITE 208
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718
Mailing Address - Country:US
Mailing Address - Phone:413-464-4590
Mailing Address - Fax:
Practice Address - Street 1:1902 W. DICKERSON ST.
Practice Address - Street 2:SUITE 208
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718
Practice Address - Country:US
Practice Address - Phone:413-464-4590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-11
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9302103TC0700X
NY019708103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical