Provider Demographics
NPI:1770688228
Name:MICSKO, MICHELLE MARIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:MARIE
Last Name:MICSKO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 HILLCREST RD E
Mailing Address - Street 2:
Mailing Address - City:LAKE QUIVIRA
Mailing Address - State:KS
Mailing Address - Zip Code:66217-8782
Mailing Address - Country:US
Mailing Address - Phone:913-631-3800
Mailing Address - Fax:913-948-7317
Practice Address - Street 1:515 HILLCREST RD E
Practice Address - Street 2:
Practice Address - City:LAKE QUIVIRA
Practice Address - State:KS
Practice Address - Zip Code:66217-8782
Practice Address - Country:US
Practice Address - Phone:913-631-3800
Practice Address - Fax:913-948-7317
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPY01595103TC0700X
KS0818103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1255098349OtherNPI