Provider Demographics
NPI:1326399437
Name:MICK, EMILY JANE (MED)
Entity type:Individual
Prefix:MS
First Name:EMILY
Middle Name:JANE
Last Name:MICK
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-1312
Mailing Address - Country:US
Mailing Address - Phone:405-561-1810
Mailing Address - Fax:405-265-8071
Practice Address - Street 1:317 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-1312
Practice Address - Country:US
Practice Address - Phone:405-561-1810
Practice Address - Fax:405-265-8071
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-28
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5189101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional