Healthcare Provider Details

I. General information

NPI: 1003772658
Provider Name (Legal Business Name): HALEY ELIZABETH MIKKELSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2025
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42415 NORTHVILLE PLACE DR
NORTHVILLE MI
48167-3100
US

IV. Provider business mailing address

42415 NORTHVILLE PLACE DR
NORTHVILLE MI
48167-3100
US

V. Phone/Fax

Practice location:
  • Phone: 401-742-8307
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7152001389
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: