Provider Demographics
NPI:1871209668
Name:BIRDSONG, MIKO REANN
Entity type:Individual
Prefix:
First Name:MIKO
Middle Name:REANN
Last Name:BIRDSONG
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 1:1725 IMPERIAL CT
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-8633
Mailing Address - Country:US
Mailing Address - Phone:575-219-2505
Mailing Address - Fax:
Practice Address - Street 1:1725 IMPERIAL CT
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-8633
Practice Address - Country:US
Practice Address - Phone:575-219-2505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-25
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SWB-2022-1021104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM3710730677Medicaid