Provider Demographics
NPI:1134467780
Name:MICKENS, SHELLY (MS, ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:MICKENS
Suffix:
Gender:F
Credentials:MS, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 COX RD
Mailing Address - Street 2:STE 301
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-3320
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4101 COX RD
Practice Address - Street 2:STE 301
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23060-3320
Practice Address - Country:US
Practice Address - Phone:804-270-7750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-16
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260002352255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer