Healthcare Provider Details

I. General information

NPI: 1255002671
Provider Name (Legal Business Name): MICHAELA MAHAKIJKITTICHAI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHAELA LEAHY

II. Dates (important events)

Enumeration Date: 09/24/2021
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 7TH ST SW
ROCHESTER MN
55902-2052
US

IV. Provider business mailing address

615 7TH ST SW
ROCHESTER MN
55902-2052
US

V. Phone/Fax

Practice location:
  • Phone: 507-328-3000
  • Fax:
Mailing address:
  • Phone: 507-328-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number5288
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number1028823
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: