Healthcare Provider Details

I. General information

NPI: 1861135048
Provider Name (Legal Business Name): ROSS G MICKELSON LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2022
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 N 2ND ST APT 311
MINNEAPOLIS MN
55401-2768
US

IV. Provider business mailing address

25545 RIVER HILLS LN
DETROIT LAKES MN
56501-7165
US

V. Phone/Fax

Practice location:
  • Phone: 218-234-6789
  • Fax:
Mailing address:
  • Phone: 218-234-6789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1029-9-15-19-458
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1029-9-15-19-458
License Number StateND
# 4
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number1029-9-15-19-458
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: