Healthcare Provider Details

I. General information

NPI: 1033041348
Provider Name (Legal Business Name): CHRISTOPHER CARL MICKELSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 8TH ST S STE 3
MOORHEAD MN
56560-3658
US

IV. Provider business mailing address

3727 17TH ST S
MOORHEAD MN
56560-7052
US

V. Phone/Fax

Practice location:
  • Phone: 218-284-1800
  • Fax:
Mailing address:
  • Phone: 651-307-1060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number30769
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: