Provider Demographics
NPI:1447933973
Name:MICKENS, KISHA WYNNETTE (LPC)
Entity type:Individual
Prefix:MS
First Name:KISHA
Middle Name:WYNNETTE
Last Name:MICKENS
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 1:3210 MATTAPONI AVE
Mailing Address - Street 2:
Mailing Address - City:WEST POINT
Mailing Address - State:VA
Mailing Address - Zip Code:23181-9307
Mailing Address - Country:US
Mailing Address - Phone:804-767-0973
Mailing Address - Fax:
Practice Address - Street 1:3210 MATTAPONI AVE
Practice Address - Street 2:
Practice Address - City:WEST POINT
Practice Address - State:VA
Practice Address - Zip Code:23181-9307
Practice Address - Country:US
Practice Address - Phone:804-767-0973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701012722101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional