Provider Demographics
NPI:1811380975
Name:MICO, ROXY A (LCSW)
Entity Type:Individual
Prefix:
First Name:ROXY
Middle Name:A
Last Name:MICO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10068
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96721-5068
Mailing Address - Country:US
Mailing Address - Phone:808-935-0070
Mailing Address - Fax:808-935-0070
Practice Address - Street 1:162 KINOOLE ST STE 101
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-2861
Practice Address - Country:US
Practice Address - Phone:808-935-0070
Practice Address - Fax:808-935-0070
Is Sole Proprietor?:No
Enumeration Date:2015-03-13
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HILCSW 32441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIH105719OtherPTAN
HI1275942591OtherTYPE 2 NPI