Provider Demographics
NPI:1528580776
Name:MIKESELL, ANNIE (MA, LCPC)
Entity Type:Individual
Prefix:
First Name:ANNIE
Middle Name:
Last Name:MIKESELL
Suffix:
Gender:F
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8413
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83707-2413
Mailing Address - Country:US
Mailing Address - Phone:208-614-0719
Mailing Address - Fax:
Practice Address - Street 1:410 S ORCHARD ST STE 124
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-1210
Practice Address - Country:US
Practice Address - Phone:208-146-0719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-10
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-6341101YP2500X
IDLCPC7432101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional