Provider Demographics
NPI:1588100309
Name:MICKENS, QUEAMANI (LPA)
Entity type:Individual
Prefix:
First Name:QUEAMANI
Middle Name:
Last Name:MICKENS
Suffix:
Gender:F
Credentials:LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 HENDERSON AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:TX
Mailing Address - Zip Code:77630-6325
Mailing Address - Country:US
Mailing Address - Phone:409-883-2273
Mailing Address - Fax:409-883-2274
Practice Address - Street 1:807 HENDERSON AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:TX
Practice Address - Zip Code:77630-6325
Practice Address - Country:US
Practice Address - Phone:409-883-2273
Practice Address - Fax:409-883-2274
Is Sole Proprietor?:No
Enumeration Date:2017-01-18
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37579103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist