Provider Demographics
NPI:1043860026
Name:MICK, EILEEN MELINDA (TLMFT)
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:MELINDA
Last Name:MICK
Suffix:
Gender:F
Credentials:TLMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 747
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66505-0747
Mailing Address - Country:US
Mailing Address - Phone:785-587-4300
Mailing Address - Fax:785-587-4377
Practice Address - Street 1:406 N 3RD ST STE 3
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:KS
Practice Address - Zip Code:66508-1497
Practice Address - Country:US
Practice Address - Phone:785-562-3907
Practice Address - Fax:785-587-4377
Is Sole Proprietor?:No
Enumeration Date:2019-09-12
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS3081106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist