Provider Demographics
NPI:1619547155
Name:CLAIBORNE, MICA LAKEY (MSW)
Entity Type:Individual
Prefix:MS
First Name:MICA
Middle Name:LAKEY
Last Name:CLAIBORNE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 ADDISON WAY APT 17-3F
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-9310
Mailing Address - Country:US
Mailing Address - Phone:804-590-8324
Mailing Address - Fax:
Practice Address - Street 1:2540 PROFESSIONAL RD STE 5
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-3213
Practice Address - Country:US
Practice Address - Phone:804-210-2402
Practice Address - Fax:804-302-6436
Is Sole Proprietor?:No
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040107661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical