Provider Demographics
NPI:1942759626
Name:MICKENS, MELODY
Entity Type:Individual
Prefix:
First Name:MELODY
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 1:1201 BROAD ROCK BLVD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23103
Mailing Address - Country:US
Mailing Address - Phone:804-337-2146
Mailing Address - Fax:
Practice Address - Street 1:1201 BROAD ROCK BOULEVARD
Practice Address - Street 2:2B-271
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23294-4915
Practice Address - Country:US
Practice Address - Phone:804-675-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-23
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810005496103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical