Healthcare Provider Details

I. General information

NPI: 1114391513
Provider Name (Legal Business Name): MICHELLE AUSTIN LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2015
Last Update Date: 11/24/2025
Certification Date: 11/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2104 PARK AVE
MINNEAPOLIS MN
55404-6607
US

IV. Provider business mailing address

100 E LYON AVE
LAKE CITY MN
55041-1014
US

V. Phone/Fax

Practice location:
  • Phone: 952-649-0512
  • Fax:
Mailing address:
  • Phone: 507-474-1985
  • Fax: 507-474-0345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number17800
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: