Healthcare Provider Details

I. General information

NPI: 1316410079
Provider Name (Legal Business Name): SIERRA MIKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2019
Last Update Date: 04/25/2024
Certification Date: 04/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9245 QUANTRELLE AVE NE
OTSEGO MN
55330-0168
US

IV. Provider business mailing address

1900 SILVER LAKE RD NW
NEW BRIGHTON MN
55112-1786
US

V. Phone/Fax

Practice location:
  • Phone: 763-746-9492
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: