MEDICARE: MRS. MICHELLE CHRISTINA MATTISON LMSW, LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker
2	1041C0700X	Clinical Social Worker	6801114209	MI

General Provider Information

NPI Number	:	1568933273
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MICHELLE CHRISTINA MATTISON LMSW, LICSW

Provider Business Mailing Address
First Line	:	12900 TECHNOLOGY DR APT 220
Second Line	:
City	:	EDEN PRAIRIE
State	:	MN
Zip	:	55344-2900
Country	:	US
Telephone Number	:	248-252-7668
Fax Number	:

Provider Business Practice Location Address
First Line	:	762 TRANSFER RD
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55114-4506
Country	:	US
Telephone Number	:	517-281-8436
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/07/2018
Last Update Date	:	08/30/2022

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