Healthcare Provider Details

I. General information

NPI: 1831108828
Provider Name (Legal Business Name): MICHAEL THOMAS MYNCZYWOR LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2006
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

618 ASH STREET SOUTH
SAUK CENTRE MN
56378
US

V. Phone/Fax

Practice location:
  • Phone: 320-255-6480
  • Fax: 320-255-6472
Mailing address:
  • Phone: 320-351-9757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number16646
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: