Provider Demographics
NPI:1609639160
Name:MICKENS, LINDA
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
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 1:1130 HURRICANE SHOALS RD NE STE 1800
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-4849
Mailing Address - Country:US
Mailing Address - Phone:470-740-0355
Mailing Address - Fax:
Practice Address - Street 1:1130 HURRICANE SHOALS RD NE STE 1800
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-4849
Practice Address - Country:US
Practice Address - Phone:470-740-0355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-06
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst