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General NPI Number Information
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NPI Number | 1376699215
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Entity Type | Individual
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Provider Name | KRISTIN MARIE MYCKE LCSW
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Gender | Female
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Dates
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Enumeration Date | 01/25/2007
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Last Update Date | 08/04/2025
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Provider Practice Location Address
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Address Line | 12990 COUNTY ROAD 3819
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City | ATHENS
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State | TX
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Zip | 75752-6621
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Country | US
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Telephone | 469-261-7019
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Fax |
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Provider Business Mailing Address
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Address Line | 12990 COUNTY ROAD 3819
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City | ATHENS
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State | TX
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Zip | 75752-6621
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Country | US
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Telephone | 469-261-7019
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number | S40023
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 40023
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License Number State | TX
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