Healthcare Provider Details

I. General information

NPI: 1669109245
Provider Name (Legal Business Name): ASHLEY C MICKLE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ASHLEY CARLITA COLES LCSW

II. Dates (important events)

Enumeration Date: 08/04/2022
Last Update Date: 09/20/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2116 W LABURNUM AVE
RICHMOND VA
23227-4359
US

IV. Provider business mailing address

PO BOX 780125
PHILADELPHIA PA
19178-0125
US

V. Phone/Fax

Practice location:
  • Phone: 804-254-3500
  • Fax: 804-254-1616
Mailing address:
  • Phone: 804-922-4844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904014234
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: