Provider Demographics
NPI:1376909127
Name:MICKAN, PENNY (MS)
Entity Type:Individual
Prefix:MRS
First Name:PENNY
Middle Name:
Last Name:MICKAN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30230 OAKMONT DR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-1109
Mailing Address - Country:US
Mailing Address - Phone:512-869-4536
Mailing Address - Fax:
Practice Address - Street 1:4402 WILLIAMS DR
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-1300
Practice Address - Country:US
Practice Address - Phone:512-256-7627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-10
Last Update Date:2016-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13962235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist