Provider Demographics
NPI:1407408974
Name:MICKENS, ROYALITTA ANGEL
Entity Type:Individual
Prefix:
First Name:ROYALITTA
Middle Name:ANGEL
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 1:1111 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94103-1589
Mailing Address - Country:US
Mailing Address - Phone:415-863-3883
Mailing Address - Fax:415-863-7343
Practice Address - Street 1:1111 MARKET ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94103-1589
Practice Address - Country:US
Practice Address - Phone:415-863-3883
Practice Address - Fax:415-863-7343
Is Sole Proprietor?:No
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)