Provider Demographics
NPI:1316473994
Name:MAMMEN, MICAH (PSYCHOLOGIST)
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:MAMMEN
Suffix:
Gender:F
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 W CHANDLER BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-6100
Mailing Address - Country:US
Mailing Address - Phone:480-524-0990
Mailing Address - Fax:
Practice Address - Street 1:1600 W CHANDLER BLVD STE 110
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-6100
Practice Address - Country:US
Practice Address - Phone:480-524-0990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-03
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZPSY-005068103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program