Healthcare Provider Details

I. General information

NPI: 1538704465
Provider Name (Legal Business Name): JOSEPH MICCI III PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2019
Last Update Date: 08/18/2021
Certification Date: 05/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1006 N BOWEN RD STE 126
ARLINGTON TX
76012-2800
US

IV. Provider business mailing address

1006 N BOWEN RD STE 126
ARLINGTON TX
76012-2800
US

V. Phone/Fax

Practice location:
  • Phone: 682-478-5333
  • Fax:
Mailing address:
  • Phone: 682-478-5333
  • Fax: 682-499-7705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP145011
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: