Provider Demographics
NPI:1700630670
Name:MICKENS-MILLER, SHANDA L (LMT)
Entity Type:Individual
Prefix:
First Name:SHANDA
Middle Name:L
Last Name:MICKENS-MILLER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 E FORNANCE ST
Mailing Address - Street 2:
Mailing Address - City:NORRISTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19401-3509
Mailing Address - Country:US
Mailing Address - Phone:610-724-4540
Mailing Address - Fax:
Practice Address - Street 1:415 E FORNANCE ST
Practice Address - Street 2:
Practice Address - City:NORRISTOWN
Practice Address - State:PA
Practice Address - Zip Code:19401-3509
Practice Address - Country:US
Practice Address - Phone:610-724-4540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-16
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG008849225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist