Healthcare Provider Details

I. General information

NPI: 1194315069
Provider Name (Legal Business Name): SHELLY MYUME EMI FICKES LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2021
Last Update Date: 01/24/2021
Certification Date: 01/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

724 S CENTRAL AVE
MEDFORD OR
97501-7851
US

IV. Provider business mailing address

724 S CENTRAL AVE
MEDFORD OR
97501-7851
US

V. Phone/Fax

Practice location:
  • Phone: 541-249-7724
  • Fax: 541-325-4055
Mailing address:
  • Phone: 541-249-7724
  • Fax: 541-325-4055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL10457
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: