Provider Demographics
NPI:1407085236
Name:MCMICKEN, CAROLYN T (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:T
Last Name:MCMICKEN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 NEWPORT LN
Mailing Address - Street 2:
Mailing Address - City:NORTH WALES
Mailing Address - State:PA
Mailing Address - Zip Code:19454-1458
Mailing Address - Country:US
Mailing Address - Phone:215-699-6356
Mailing Address - Fax:
Practice Address - Street 1:104 NEWPORT LN
Practice Address - Street 2:
Practice Address - City:NORTH WALES
Practice Address - State:PA
Practice Address - Zip Code:19454-1458
Practice Address - Country:US
Practice Address - Phone:215-699-6356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-14
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103G00000X
PAPS016116103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist