Provider Demographics
NPI:1316192073
Name:MICKENS, LAVONDA K (PHD)
Entity Type:Individual
Prefix:DR
First Name:LAVONDA
Middle Name:K
Last Name:MICKENS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5801 ARMY PENTAGON CORRIDOR 8, ROOM 130
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20301-5801
Mailing Address - Country:US
Mailing Address - Phone:703-614-6562
Mailing Address - Fax:
Practice Address - Street 1:5801 ARMY PENTAGON CORRIDOR 8, ROOM 130
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20301-5801
Practice Address - Country:US
Practice Address - Phone:703-614-6562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-22
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC2200X
CA25833103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent