Provider Demographics
NPI:1194315069
Name:FICKES, SHELLY MYUME EMI (LCSW)
Entity type:Individual
Prefix:
First Name:SHELLY MYUME
Middle Name:EMI
Last Name:FICKES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:724 S CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-7851
Mailing Address - Country:US
Mailing Address - Phone:541-249-7724
Mailing Address - Fax:541-325-4055
Practice Address - Street 1:724 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-7851
Practice Address - Country:US
Practice Address - Phone:541-249-7724
Practice Address - Fax:541-325-4055
Is Sole Proprietor?:No
Enumeration Date:2021-01-24
Last Update Date:2021-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL104571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical