Provider Demographics
NPI:1487768594
Name:MICKELSON, KIMBERLY E (LPC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:E
Last Name:MICKELSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2303 RAUN LN
Mailing Address - Street 2:
Mailing Address - City:EL CAMPO
Mailing Address - State:TX
Mailing Address - Zip Code:77437-2127
Mailing Address - Country:US
Mailing Address - Phone:979-541-3375
Mailing Address - Fax:
Practice Address - Street 1:2303 RAUN LN
Practice Address - Street 2:
Practice Address - City:EL CAMPO
Practice Address - State:TX
Practice Address - Zip Code:77437-2127
Practice Address - Country:US
Practice Address - Phone:979-541-3375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17777101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164430404OtherDOCS MCD
TX164430403OtherDOMHA MCD
TX164430402Medicaid