Provider Demographics
NPI:1598083560
Name:MCMICKENS, COURTNEY LOCKHART (MD)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LOCKHART
Last Name:MCMICKENS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:LOUKETRA
Other - Last Name:LOCKHART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:720 HARRISON AVE
Mailing Address - Street 2:DOB 503
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2371
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 BOSTON MEDICAL CTR PL
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2908
Practice Address - Country:US
Practice Address - Phone:617-414-5245
Practice Address - Fax:617-638-6826
Is Sole Proprietor?:No
Enumeration Date:2010-05-14
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2547552084P0800X, 2084P0804X
NY3033012084P0804X
NC2018-016112084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry