Provider Demographics
NPI:1598198962
Name:MICKENS, WILLIAM (QMHP)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:
Last Name:MICKENS
Suffix:
Gender:M
Credentials:QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5833 RICHMOND TAPPAHANNOCK HWY # 108
Mailing Address - Street 2:
Mailing Address - City:AYLETT
Mailing Address - State:VA
Mailing Address - Zip Code:23009-3007
Mailing Address - Country:US
Mailing Address - Phone:804-387-0426
Mailing Address - Fax:
Practice Address - Street 1:5833 RICHMOND TAPPAHANNOCK HWY # 108
Practice Address - Street 2:
Practice Address - City:AYLETT
Practice Address - State:VA
Practice Address - Zip Code:23009-3007
Practice Address - Country:US
Practice Address - Phone:804-387-0426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-20
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2063251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health