Provider Demographics
NPI:1235918152
Name:MICKENS, CHRISTIAN
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:
Last Name:MICKENS
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 1:2983 BLUE STONE CT
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-7681
Mailing Address - Country:US
Mailing Address - Phone:404-729-5471
Mailing Address - Fax:
Practice Address - Street 1:1559 JANMAR RD
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-5606
Practice Address - Country:US
Practice Address - Phone:770-336-7373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-28
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician