Provider Demographics
NPI:1992383103
Name:MICKINS, DE'VONCIA LACHEL
Entity Type:Individual
Prefix:
First Name:DE'VONCIA
Middle Name:LACHEL
Last Name:MICKINS
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 1:855 OLD HOMESTEAD RD
Mailing Address - Street 2:
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28504-6854
Mailing Address - Country:US
Mailing Address - Phone:252-521-0773
Mailing Address - Fax:
Practice Address - Street 1:104 E OLD US 74/76
Practice Address - Street 2:
Practice Address - City:LAKE WACCAMAW
Practice Address - State:NC
Practice Address - Zip Code:28450-1927
Practice Address - Country:US
Practice Address - Phone:252-521-0773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-30
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0153831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical