Provider Demographics
NPI:1174963144
Name:MICKEY, MELANIE REYNOLDS (LMHC)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:REYNOLDS
Last Name:MICKEY
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9654 RAGSDALE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-6121
Mailing Address - Country:US
Mailing Address - Phone:904-891-9365
Mailing Address - Fax:
Practice Address - Street 1:9654 RAGSDALE DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-6121
Practice Address - Country:US
Practice Address - Phone:904-891-9365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-05
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
FLMH11303101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL462088732OtherTRICARE