Healthcare Provider Details

I. General information

NPI: 1326055872
Provider Name (Legal Business Name): MICHAEL JAMES MATHIES LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 VETERANS DR
SAINT CLOUD MN
56303-2015
US

IV. Provider business mailing address

1012 10TH AVE NE
SAUK RAPIDS MN
56379-9657
US

V. Phone/Fax

Practice location:
  • Phone: 320-255-6480
  • Fax:
Mailing address:
  • Phone: 320-493-3686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number14810
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: