Provider Demographics
NPI:1649266388
Name:MICKLES, JUSTIN M (MS)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:M
Last Name:MICKLES
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:695 FOX TRAIL CT
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-6251
Mailing Address - Country:US
Mailing Address - Phone:615-853-1254
Mailing Address - Fax:
Practice Address - Street 1:933 TRACY LN STE D
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-6894
Practice Address - Country:US
Practice Address - Phone:931-542-6637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-27
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4954101YP2500X
NE1485101YP2500X
NE57101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional