Provider Demographics
NPI:1942573282
Name:PRICE, MICKEY J (PSYD)
Entity Type:Individual
Prefix:
First Name:MICKEY
Middle Name:J
Last Name:PRICE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 7TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415-9209
Mailing Address - Country:US
Mailing Address - Phone:541-787-8776
Mailing Address - Fax:
Practice Address - Street 1:919 7TH ST
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-9209
Practice Address - Country:US
Practice Address - Phone:541-787-8776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-16
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20090103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist