Provider Demographics
NPI:1952703167
Name:MICKEL, KRISTIN LYNN (PSYD)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:LYNN
Last Name:MICKEL
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 1:500 N MAITLAND AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-4482
Mailing Address - Country:US
Mailing Address - Phone:407-628-5354
Mailing Address - Fax:407-628-0254
Practice Address - Street 1:500 N MAITLAND AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-4482
Practice Address - Country:US
Practice Address - Phone:407-628-5354
Practice Address - Fax:407-628-0254
Is Sole Proprietor?:No
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY9141103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical