Provider Demographics
NPI:1346995818
Name:MIKLE, KRYSTALLYNNE SHANIELLE (PHD, LCSW, MSW, BSW)
Entity Type:Individual
Prefix:DR
First Name:KRYSTALLYNNE
Middle Name:SHANIELLE
Last Name:MIKLE
Suffix:
Gender:F
Credentials:PHD, LCSW, MSW, BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21898 FM 1314 ROAD
Mailing Address - Street 2:SUITE C PMB 104
Mailing Address - City:PORTER
Mailing Address - State:TX
Mailing Address - Zip Code:77365
Mailing Address - Country:US
Mailing Address - Phone:832-556-3079
Mailing Address - Fax:832-556-3079
Practice Address - Street 1:21898 FM 1314 ROAD SUITE C PMB 104
Practice Address - Street 2:SUITE C PMB 104
Practice Address - City:PORTER
Practice Address - State:TX
Practice Address - Zip Code:77365
Practice Address - Country:US
Practice Address - Phone:832-556-3079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-14
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX50664101Y00000X, 101YM0800X, 101YP2500X, 104100000X, 1041C0700X
251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No251B00000XAgenciesCase Management