Healthcare Provider Details

I. General information

NPI: 1467316356
Provider Name (Legal Business Name): MIA TICKEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4342 15TH AVE S STE 105
FARGO ND
58103-1125
US

IV. Provider business mailing address

1919 UNIVERSITY DR N APT 314
FARGO ND
58102-1844
US

V. Phone/Fax

Practice location:
  • Phone: 701-936-9495
  • Fax:
Mailing address:
  • Phone: 701-429-4315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: