Healthcare Provider Details

I. General information

NPI: 1205466125
Provider Name (Legal Business Name): MICHAEL PROEBSTLE MA, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2020
Last Update Date: 01/20/2020
Certification Date: 01/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4141 OLD SIBLEY MEMORIAL HWY
EAGAN MN
55122-1996
US

IV. Provider business mailing address

3763 DENMARK TRL W
EAGAN MN
55123-1010
US

V. Phone/Fax

Practice location:
  • Phone: 612-888-3858
  • Fax:
Mailing address:
  • Phone: 612-888-3858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number2310
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: