Provider Demographics
NPI:1033110812
Name:MICKLOS, PATRICIA JANE (PSYD)
Entity type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:JANE
Last Name:MICKLOS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 AUSTIN AVE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76701-1902
Mailing Address - Country:US
Mailing Address - Phone:254-753-7444
Mailing Address - Fax:254-714-1737
Practice Address - Street 1:900 AUSTIN AVE
Practice Address - Street 2:SUITE 500
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76701-1902
Practice Address - Country:US
Practice Address - Phone:254-753-7444
Practice Address - Fax:254-714-1737
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22596103TC0700X
TX001559-042699103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00G434Medicare ID - Type UnspecifiedPSYCHOLOGIST