Provider Demographics
NPI:1982152328
Name:MICKENS, CONSTANCE (PLMSW)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:
Last Name:MICKENS
Suffix:
Gender:F
Credentials:PLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 CALVIN AVERY DR
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-6501
Mailing Address - Country:US
Mailing Address - Phone:870-732-1878
Mailing Address - Fax:870-702-1878
Practice Address - Street 1:304 N 6TH ST
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-3221
Practice Address - Country:US
Practice Address - Phone:870-702-7111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR214805795Medicaid