Provider Demographics
NPI:1831887397
Name:MICKENS, TIMARA NICOLE
Entity type:Individual
Prefix:
First Name:TIMARA
Middle Name:NICOLE
Last Name:MICKENS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 SOUTHPORT DR
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-7082
Mailing Address - Country:US
Mailing Address - Phone:843-408-5798
Mailing Address - Fax:
Practice Address - Street 1:491 CHAPMAN RD LOT 111
Practice Address - Street 2:
Practice Address - City:FOUNTAIN INN
Practice Address - State:SC
Practice Address - Zip Code:29644-6139
Practice Address - Country:US
Practice Address - Phone:843-408-5798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-24
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician