Provider Demographics
NPI:1740664648
Name:KIRK, MIKETO MICHELLE (AA, LAC)
Entity type:Individual
Prefix:
First Name:MIKETO
Middle Name:MICHELLE
Last Name:KIRK
Suffix:
Gender:F
Credentials:AA, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1902 E LOOMAN ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67219-4532
Mailing Address - Country:US
Mailing Address - Phone:316-267-5710
Mailing Address - Fax:
Practice Address - Street 1:2050 WEST 11TH ST.
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203
Practice Address - Country:US
Practice Address - Phone:316-267-5710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-10
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS680101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)